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State of New Mexico - Taxation and Revenue Department

RPD-41283

INT. 10/2003

ANNUAL SUMMARY OF OIL AND GAS PROCEEDS WITHHOLDING TAX

Who Must File This Form:

Remitters (payors) of oil and gas rents and royalties from property located in New Mexico who are required

to file federal Form 1099-MISC, and remitters of oil and gas proceeds from oil and gas production from wells located in New Mexico who

have withheld tax from payment(s) according to the Oil and Gas Proceeds Withholding Tax Act (7-3A-1 NMSA 1978) must submit to the

Department Form RPD-41283, Annual Summary of Oil and Gas Proceeds Withholding Tax and an annual statement of withholding for

each remittee. See page 2 for a description of the annual statement of withholding form to use. The annual summary must reflect the

total oil and gas proceeds withholding tax withheld and reported to the Department on Form RPD-41284, Quarterly Oil and Gas Proceeds

Withholding Tax Return. Form RPD-41283 and attachments are due to the Department by the last day of February of the year following

the calendar year in which the payments were withheld. If the due date falls on a Saturday, Sunday, state or national legal holiday, the

return is timely if the postmark bears the date of the next business day.

Mail the form to New Mexico Taxation and Revenue Department , P.O. Box 25127, Santa Fe, NM 87504-5127. For assistance, contact (505)

827-0825.

PART I. Complete the following information about your company and the Reporting Year. (e.g. 2003)

Name and address of remitter of oil and gas proceeds

Taxable Year

Federal employer identification number or

social security number

New Mexico CRS identification number

Name of person to contact

E-mail address

Telephone number

PART II. Schedule of New Mexico income tax withheld and reported on Form RPD-41284. Enter the New Mexico income

tax withheld and reported to the Department on Form RPD-41284, Quarterly Oil and Gas Proceeds Withholding Tax Return, for

each quarter during the reporting year. The reporting month is the month in which the taxes were withheld and not the month the

tax was due. Enter the sum of the tax withheld.

QUARTERLY REPORT PERIOD

AMOUNT

1.January through March

2.April through June

3.July through September

4.October through December

TOTAL

PART III. Complete lines 1 through 4 below. Reconcile the New Mexico income tax withheld and reported on Form RPD-41284,

to the New Mexico income tax withheld and reported on federal Form 1099-MISC, or RPD-41285, Annual Statement of Withholding

of Oil and Gas Proceeds.

Enter the number of annual statements of withholding submitted. (Include all forms whether

attached or filed via magnetic media or Combined Federal/State Program) ........................................................

Total New Mexico income tax withheld for the taxable year as shown on Federal Forms

1099-MISC .............................................................................................................................................................

Total New Mexico income tax withheld and reported on Form RPD-41284 during the reporting year ..............

Difference (See Other Attachments below) ........................................................................................................

PART IV. Sign and date the report. (See Required Attachments on page 2)

I declare that I have examined this return and accompanying documents, and to the best of my knowledge and belief, they are true,

correct, and complete.

Signature:

Title:

Date:

Form Rpd-41283 - Annual Summary Of Oil And Gas Proceeds Withholding Tax - State Of New Mexico Taxation And Revenue Department

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