RPD-41205
State of New Mexico - Taxation & Revenue Department
Rev. 03/2011
Unclaimed Property Office
P.O. Box 25123
Santa Fe, New Mexico 87504-5123
(505) 827-0767 or 827-0668
HOLDER'S NEGATIVE REPORT
Name of Holder
Address
ZIP Code
State
City
Federal ID Number
Telephone Number
(
)
E-mail Addresss
The above named holder has no unclaimed property to file with the State of New
Mexico for the ____________ Annual Report Year of the Period Ending June 30,
____________.
I declare that I have examined this report and, to the best of my knowlege and
belief, it is true, correct and complete.
Printed Name
Title
Date
Signature