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Form Rpd-41247 - Certificate Of Eligibility For The Rural Job Tax Credit - State Of New Mexico Taxation And Revenue Department

State of New Mexico - Taxation & Revenue Department

RPD-41247

Rev. 12/12/2011

CERTIFICATE OF ELIGIBILITY FOR THE RURAL JOB TAX CREDIT

Purpose of Form. Form RPD-41247 is to be used by a qualified employer to supplement a claim for the Rural Job Tax

Credit. This form certifies the wages of an eligible employee during a qualified period for a qualified job. See the instructions

for important definitions.

How to File this Form. To apply for the Rural Job Tax Credit, complete Form RPD-41238 Application for Rural Job Tax

Credit. Attach Form RPD-41247, Certificate of Eligibility for the Rural Job Tax Credit, for each qualified job in the eligible

period claimed. Summarize the total eligible jobs and the wages on Form RPD-41238, Application for Rural Job Tax Credit.

Submit all documentation to the Taxation and Revenue Department for approval. Once the credit is approved, you will

receive notification from the Department. See the instructions for Form RPD-41238, Application for Rural Job Tax Credit,

for further details.

For the status of the credit application call (505) 841-6478.

Name of eligible employer

New Mexico CRS identification number

Physical address

City, state and ZIP code

Mailing address

Name of contact

Phone number

Fax number

1. The date the qualifying job was created:

2. Name of eligible employee(s) :

3. The qualifying period for this certificate is:

through

(mmyy)

4. The number of qualified periods previously claimed for this qualifying job:

I certify that:

(Mark the boxes that apply and complete the required information.)

the person employed in this qualified period is an eligible employee as defined in 7-2E-1.1 NMSA 1978

(see reverse).

wages paid to the eligible employee during this qualified period were: $

number of weeks during the qualifying period (see reverse) that the position was occupied :

the qualifying job is located in a:

tier one

tier two area. (See reverse for definition.)

Under penalty of perjury I declare that I have examined this claim, and to the best of my knowledge and belief it is

true, correct and complete.

Date

Signature of claimant

, 20

Subscribed and sworn before me this

day of

Notary Public

My commission expires

Form Rpd-41247 - Certificate Of Eligibility For The Rural Job Tax Credit - State Of New Mexico Taxation And Revenue Department

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