Form Rpd-41344 - Native American Veterans Income Tax Settlement Fund Claim (Page 2 of 5) in pdf

Form Rpd-41344 - Native American Veterans Income Tax Settlement Fund Claim Page 2

RPD-41344

State of New Mexico - Department of Veterans Services

Rev. 07/2010

NATIVE AMERICAN VETERANS

Income Tax Settlement Fund Claim

(Page 1 of 3)

Please complete this application for a settlement payment if you are a Native American Veteran who maintained a home on

tribal land during your military service and had New Mexico income tax withheld on any of your active duty military pay.

Mail completed Form RPD-41344, Native American Veterans Income Tax Settlement Fund Claim, and attachments to:

Alan Martinez, Deputy Secretary, Department of Veterans Services, P O Box 2324, Santa Fe, NM 87504-2324. Telephone

number is 866-433-8387.

Part 1. Veteran's Information

Name of veteran (first, middle, last)

Social security number

Name of veteran as indicated on DD Form 214, if different.

Current mailing address. Give us the address where you currently receive your mail.

Mailing address

City, state and ZIP code

Part 2. Veteran's Status as a Native American

Name of New Mexico federally recognized Indian nation, tribe or pueblo of which the veteran or

If only the spouse is an enrolled member of an

the veteran's spouse is an enrolled member.

Indian nation, tribe or pueblo, enter the spouse's

name.

Part 3. Military Service

Enter the branch of service and the dates of active duty in the Armed Forces of the United States. To verify the active duty

period, attach Form(s) DD Form 214 and mark the box below indicating the form(s) is attached or mark the box to authorize

the Department of Veterans Services to request a copy of the form from the Department of Defense.

Dates of military service

Branch of Service

From

Check one.

‰

DD Form 214 is attached,

‰

I authorize the Department of Veterans Services to request a copy of the claimant's DD Form 214 from the

Department of Defense.

(Continued on the next page.)

Form Rpd-41344 - Native American Veterans Income Tax Settlement Fund Claim Page 2