Form RPD-41271 Declaration of Residency - Film Production Tax Credit

1 Are you a New Mexico resident? See Residency above YES NO 2 You must provide evidence (select one below) to show proof of residency and be able to physically show the production proof Please check the applicable box and attach proof to this form A copy of last year s New Mexico personal income tax return (filing as a Resident or First Year Resident) A valid New Mexico s driver s license Enter driver s license number: Voter registration card Enter the registering county: Other Indicate Type: Other evidence must be clear and convincing and show intent to maintain a permanent residence in New Mexico Proof of ownership of property or establishing an abode in New Mexico is not acceptable unless supplemented by other information showing intent 3 What type of New Mexico tax return do you file or intend to file? Resident First Year Resident Part Year Resident Non Resident 4 Do you understand that you are signing this form under penalty of perjury? YES NO (film production company name) to act as my representative for disclosure of my residency status administered by the New Mexico Taxation & Revenue Department *Important Notes: If it is discovered that the applicant filed a New Mexico Non Resident or Part Year Resident City State and ZIP Code Telephone Number DECLARATION OF RESIDENCY Film Production Company: Please complete highlighted line and retain the completed form for your records New Mexico Resident: Please complete the box below sign and date Film Project Title Position I declare under penalty of perjury that I have completed this document to the best of my knowledge and verify that it is true correct and complete By signing this form I authorize means New Mexico is your permanent home; 2) you must file or intend to file a New Mexico tax return as a Name (please print) Social Security Number New Mexico Resident s Signature Date Permanent Residence physical address (P O boxes not accepted) Purpose of this form: To assist film production companies in determining New Mexico residency Residency: To be a resident of New Mexico for tax purposes 1) you must be domiciled in New Mexico which Resident or First Year Resident; and 3) you must be domiciled in New Mexico on the last day of the taxable year December 31 RPD 41271 STATE OF NEW MEXICO TAXATION AND REVENUE DEPARTMENT Rev 02/2010 tax return or if the Taxation & Revenue Department has other evidence indicating the applicant is not a resident (even though the applicant completed this form and provided evidence) the applicant will not qualify for the film production tax credit It should also be noted that the applicant is completing and signing this form under penalty of perjury