Form Rpd-41344 - Native American Veterans Income Tax Settlement Fund Claim (Page 3 of 5) in pdf

RPD-41344

State of New Mexico - Department of Veterans Services

Rev. 07/2010

NATIVE AMERICAN VETERANS

Income Tax Settlement Fund Claim

(Page 2 of 3)

Part 4. Residency on Tribal Land During Period of Active Duty

Box must be marked in order to qualify for settlement payment.

‰

The claimant's (or claimant's spouse's) home of record address for the entire period of the claimant's military service

covered by this claim is located on the Indian nation, tribe or pueblo to which the claimant or the claimant's spouse is

a member.

Part 5. Deceased Veteran

Complete Part 5 only if the veteran is deceased.

The veteran's date of death.

If the refund must be made payable to a person other than the veteran, enter the name and SSN of the person entitled to

claim the refund; otherwise, the check will be made payable to the estate of the decedent.

Name of spouse, other successor or personal representative (first, middle, last)

Social security number

Check the following two boxes to indicate the required documentation is attached.

Copy of the death certificate or other proof of death -- (An original or an authentic copy of a telegram or letter from the

‰

Department of Defense notifying the next of kin of the decedent's death will constitute proof of death.) Proof of death

must be attached if the veteran is deceased.

Affidavit to Obtain Refund of New Mexico Tax Due a Deceased Taxpayer -- Complete Form RPD-

‰

Form RPD-41083,

41083 even if you were the spouse of the veteran at the time of death. Form must be signed, dated and notarized. Form

RPD-41083 can be downloaded from the Taxation and Revenue website at

Part 6. New Mexico Income Tax Withheld

Enter below each tax year in which New Mexico income tax was withheld and the amount of New Mexico income tax with-

held from active military service during the year and reported on the federal Form W2. Attach all federal Forms W2. If you

do not have a copy of your federal Forms W2, or the attached federal Forms W2 do not represent all the tax withheld from

active military service during a year, check the box in the third column to request the Taxation and Revenue Department

obtain the claimant's W2 Form information from the Department of Defense. For each tax year listed, complete the state-

ment in the fourth column.

(1)

(2)

(3)

(4)

Amount of New Mexico income

I request the Taxation and Reve-

To the best of my knowledge, I

Tax year

tax withheld from the attached

nue Department obtain the claim-

certify that a refund for the taxes

copy of Forms W2. Enter "Do

ant's Form W2 information for the

withheld (check only one box):

not have W2" if you do not have

tax year.

a Form W2 for the year.

‰

was received

‰

Yes

‰

was not received

‰

was received

Yes

‰

was not received

(Continued on the next page.)

Form Rpd-41344 - Native American Veterans Income Tax Settlement Fund Claim Page 3

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