Form Rpd-41120 - Coal/uranium Conservation Tax Report
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2NEW MEXICO TAXATION AND REVENUE DEPARTMENT
RPD-41120
REV. 07/2010
P.O. Box 2308, Santa Fe, NM 87504-2308, (505) 827-0958
COAL/URANIUM CONSERVATION TAX REPORT
Original
Amended
1.
Federal Employer Identification Number (FEIN) ...................................................
2.
Report Period ................................................................................................................ _____ / ________
(M M - Y Y Y Y)
3.
Contract / Lease Number ......................................................................................
4.
Kind (Coal Conservation (CC) Uranium Conservation (UC)) ................................
5.
Volume (no decimals) ..........................................................................................
.
6.
Value .....................................................................................................................
.
7.
Royalty Exemption ................................................................................................
.
8.
Tax Due .................................................................................................................
.
9.
Penalty ..................................................................................................................
.
10. Interest ..................................................................................................................
.
11.
Total ......................................................................................................................
FOR TAXATION AND REVENUE DEPARTMENT USE ONLY
Validated Remittance Amount
In / Out State Check
Postmark Date
This Report Submitted by
Company Name ______________________________________ Telephone Number ( ) ________________
Address ___________________________________________________________________________________
City ________________________________________ State ____________ ZIP Code _____________________
E-mail Address ______________________________________________________________________________
This report has been examined by me and, to the best of my knowledge and belief, is true, complete and in accor-
dance with law and regulation. NOTE: This return is not complete unless signed by the taxpayer.
Signature _______________________________________ Title _______________________________________
Name ___________________________________________________ Date _______________________________________________
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