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

Form Rpd-41344 - Native American Veterans Income Tax Settlement Fund Claim Page 5

RPD-41344

Department of Veterans Services

State of New Mexico -

Rev. 07/2010

NATIVE AMERICAN VETERANS Income Tax Settlement Fund Claim

RESIDENCY STATEMENT

Purpose of this Form: A claimant for a settlement payment from the Native American Veterans Income Tax Settlement

Fund must substantiate residency on Indian nation, tribe or pueblo land during the period(s) any New Mexico personal

income tax was withheld from active duty military pay. The veteran must be a resident within the boundaries of the Indian

member's or the member's spouse's reservation or pueblo grant, or within the boundaries of lands held in trust by the United

States for the benefit of the member or spouse or the member's or spouse's nation, tribe or pueblo. If the address shown

on the claimant’s DD Form 214 is not on tribal land or the claimant cannot establish that the address is on tribal land, or the

address was not the claimant's address of record for the entire period for which the claim is being made, the claimant must

provide the following statement signed by the claimant.

Veteran's Information

Name of veteran (first, middle, last)

Social security number

Home of record (physical address or description)

Indicate the name of Indian nation, tribe or

Dates of residency

pueblo in which the address is located.

From

during period of active duty military service

Claimant:

I declare that the address(s) listed above is the home of record established for the claimant (veteran) with the Depart-

ment of Defense while in active duty military service.

_______________________________________________________________________________________________

Signature of veteran or if deceased, personal representative or legal successor

Print name

Date

Form Rpd-41344 - Native American Veterans Income Tax Settlement Fund Claim Page 5