Form Rpd-41206 - Holder'S Request For Reimbursement

Form Rpd-41206 - Holder'S Request For Reimbursement - 2011

State of New Mexico - Taxation & Revenue Department

RPD-41206

Rev. 03/2011

HOLDER'S REQUEST FOR REIMBURSEMENT

State of ________________ Report Year ________________ Report Total________________

PART I HOLDER INFORMATION

Holder Name

Address

City

State

ZIP Code

Tax ID#

Contact Name

Contact Phone Number

Contact Fax Number

Contact E-mail Address

PART II CLAIM INFORMATION

Property Code

Acct. Reference No. (if aggregate-specify)

Date Pd. to Owner/Acct. Reactivated*

Dollar Amount/Number of Shares

Owner’s Name (exactly as on Report)

Owner’s Address (as listed on Report)

Claimant’s Name & Address (if different than owner)

IF AMOUNT WAS REMITTED IN ERROR, ATTACH

Total Request for Reimbursement: $_______________

A SEPARATE SHEET DETAILING THE ERROR

PART III HOLDER CERTIFICATION

I, ______________________________, a dully authorized representative of the holder listed above, do hereby certify

that the above listed funds, or other property which was listed in the Report filed by the holder, have been paid to the

Sworn to and subscribed before me this

rightful owner(s) or their appointed representatives. I agree, upon payment of the above-described property to indem-

____________day of __________20__

nify the State and hold it harmless for all claims and losses, demands, costs, and other expenses which the State may

sustain by reason of returning property to the holder and by reason further of its refusal to pay the property to other

Notary:__________________________

person or persons:

My commission expires:____________

Name and Title of Holder Representative (type or print)________________________________________________

Signature of Holder Representative_____________________________________________Date_______________

Form Rpd-41206 - Holder'S Request For Reimbursement - 2011