Form Rpd-41054 - Wc-1 - Workers' Compensation Fee
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1STATE OF NEW MEXICO
RPD-41054
Rev. 08/2010
TAXATION AND REVENUE DEPARTMENT
WC-1 - WORKERS' COMPENSATION FEE FORM
Beginning with calendar quarter ending September 30, 2004, the quarterly workers' compensation fee paid on
Form WC-1 increased from $4 to $4.30 per covered worker (employee). Only the employer's share increased.
See the instructions for details.
WHO MUST FILE: Every employer who is covered by the Workers' Compensation Act, whether by requirement or election, must file and
pay the New Mexico Workers' Compensation Fee and file Form WC-1. See the instructions for requirements.
*IMPORTANT: On Line 1, enter the number of workers (employees) to whom the Workers' Compensation Fee applies. This is the number
of covered employees you employed on the last working day of the calendar quarter. If you have no covered employees, enter zero.
WHEN TO FILE: The Workers' Compensation Fee is due on or before the last day of the month following the close of the report period.
A report period is a calendar quarter ending March 31, June 30, September 30 and December 31.
Upon completion of this form, sign, date and enter your phone number and E-mail address on the form. Make the check or money order
payable to Taxation and Revenue Department.
Mail the bottom portion of this form with payment to
New Mexico Taxation and Revenue Department, P.O. Box 2527, Santa
. Retain the top portion for your records. For assistance call (505) 827-0832.
Fe, NM 87504-2527
REPORT PERIOD:
A. FEIN:
Beginning (mm-dd-yy)
Ending (mm-dd-yy)
B. CRS:
1. *Number of covered
workers at close of
C. EAN:
report period
1.
NAME:
$
2. Assessment fee
2.
3.
$
3. Penalty
STREET/BOX:
$
4. Interest
4.
CITY, STATE, ZIP:
$
5. Total due
5.
PLEASE CUT AND INCLUDE THE BOTTOM PORTION WITH YOUR PAYMENT
RETAIN THE UPPER PORTION FOR YOUR RECORDS
WORKERS' COMPENSATION FEE (WC-1)
REPORT PERIOD:
A. FEIN:
Beginning (mm-dd-yy)
Ending (mm-dd-yy)
B. CRS:
1. *Number of covered
workers at close of
C. EAN:
report period
1.
NAME:
$
2. Assessment fee
2.
$
3.
3. Penalty
STREET/BOX:
$
4. Interest
4.
CITY, STATE, ZIP:
$
5. Total due
5.
Check if amended
Signature ___________________________________ Phone ______________ Date _____________ E-mail address __________________________
WKC
Mail to: Taxation and Revenue Department, P.O. Box 2527, Santa Fe, NM 87504-2527
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