Request For Tax Clearance Form - 2014
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1
2State of New Mexico - Taxation and Revenue Department
ACD - 31096
DEPARTMENT USE ONLY
REV.
01/14
AUDIT & COMPLIANCE DIVISION
A. Control log number
REQUEST FOR TAX CLEARANCE
B. Date Received
SECTION
A
Name of Taxpayer for Whom Clearance is Requested
NM Taxation & Revenue Dept. ID Number
Doing Business as
Federal ID Number
Street Address of Taxpayer
Mailing Address of Taxpayer
City
State
Zip Code
Contact Name and Title
Contact Telephone Number
(
)
Date Began Doing Business in N.M.
Date Will Cease Doing Business in N.M.
Nature of business in New Mexico
Type of Request
Successor in
Corporate
Liquor License
q
q
q
Business
Withdrawal/Dissolution
Clearance
Enter Number under Item below to show which
Check if Business:
Check if any License/Permit will be:
license/permit is to be transferred.
Sold Gasoline / Special Fuel
q
Liquor License No.
q
q
q
Sold Liquor
Leased
Sold
Sold Cigarettes
q
Secretary of State Corporation No.
q
Other _____________________
q
Sold Tobacco Products
Secretary of State Permit No.
q
Severed Natural Resources
Has Liquor License been leased previously?
Processed Natural Resources
q
OGRID No.
q
q
q
Sold Oil
Yes (see instructions)
No
SECTION
B
IF BUSINESS/LICENSE/PERMIT IS TO BE OPERATED BY ANOTHER TAXPAYER GIVE NAME AND ADDRESS BELOW
Name of Purchaser/Lessee
NM Taxation & Revenue Department ID Number
Doing Business as
Telephone Number
(
)
Street Address
Mailing Address
City
State
Zip Code
SECTION C
MUST BE COMPLETED AND SIGNED
I declare I have examined this request and all attachments and to the best of my knowledge and belief the information is true, correct and complete.
Printed or Typed Name
Position or Title
Company
Signature
Date
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Parent category: Financial