RPD-41086
SEV-5
REV. 06/13
STATE OF NEW MEXICO
TAXATION AND REVENUE DEPARTMENT
REPORT OF SEVERANCE TAX - COAL
Mail the original of this report and the total amount due to the State of New Mexico, Taxation and Revenue Department, P. O. Box 2308,
Santa Fe, NM 87504-2308 on or before the 25th day of the month following the month in which the taxable event occurs.
Phone: (505) 827-0807
TAX PERIOD
Name
Address
City, State
Federal Employer Identification Number (FEIN)
and Zip Code
(Refer to this number in all correspondence)
Tax Rate Plus
Total Severance
Location
Price per Unit
Quantity
Gross Value
Type of Coal
Surtax Rate
Tax Due
(mine, mill, pit, quarry)
Penalty for late filing (2% of total tax due per month or partial month up to 20%) ...............................
IMPORTANT: See reverse
Interest for late filing (Section 7-1-67 NMSA 1978) .............................................................................
GRAND TOTAL OF TAXES, INTERGOVERNMENTAL TAX CREDIT, PENALTY AND
side for instructions.
INTEREST DUE (Remit this amount) ..................................................................................................
I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is true,
correct and complete.
________________________________
___________________________
__________________ ____________________
Signature of Taxpayer or Agent
Title
Phone No.
Mo
/ Day / Year