Form RPD-41295 Application for New Mexico Retail Food Store Certification

(Annual gross sales $2 million or more) *Use estimated ONLY if previous year information is not yet available or if this is a new store You may be required to submit actual figures when available 1 Type of business (Check one) 2 Inventory and services sold (Check all that apply) 3 Staple foods in inventory stock (Check all that apply) ALBUQUERQUE: Taxation & Revenue Department LAS CRUCES: Application for New Mexico Retail Food Store Certification for the food deduction pursuant to Section 7 9 92 NMSA 1978 Application for New Mexico Retail Food Store Certification for the food deduction pursuant to Section 7 9 92 NMSA 1978 INSTRUCTIONS Bread baked goods rice pasta cereal chips chain store unit number (if applicable) FEIN or SSN (if different) CHECK if applicable: The retail food store described in this application is requesting eligibility for New Mexico retail store certification retroactive to January 1 2005 The description of this retail store operation contained within this application has been in effect since on or before January 1 2005 Check the inventory and services at this store from choices listed below: Check the staple foods in inventory at this store from the choices listed below: Eggs City state and zip code Complete either Section A or B using the terms defined in the instructions Complete this application and submit it to the department When approved you will receive a New Mexico Retail Food Store Certification and may begin taking the deduction for qualified sales of certain foods pursuant to Section 7 9 92 NMSA 1978 Mark the box in PART 1 if you are requesting certification retroactive to January 1 2005 Completing this form: File one application for each location Complete all parts of this application and all information as requested or your application may be returned without review Be sure to transfer the business name and the CRS identifica tion number from the first page to the top of the second page Sign the application Mail the completed application to the local district tax office nearest you The phone numbers of the local district tax offices are also included in the listing below If approved your application will be returned to you with department approval Contact name phone number and e mail address Convenience store cookies crackers etc ) Canned/frozen/packaged staple foods Dairy Products (milk cheese butter yogurt etc ) (including 100% juices) Farmington NM 87499 0479 FARMINGTON: Taxation & Revenue Department P O Box 479 Telephone: 505/624 6065 Federal income tax year Annual retail food sales at this location as reported to the IRS for the last two years Annual gross sales at this location as reported to the IRS for the last two years FOR DEPARTMENT USE ONLY This application for New Mexico Retail Food Store Certification was reviewed by the New Mexico Taxation and Revenue Department and was approved Name of Certified New Mexico retail food store Date of approvalAuthorized Department Signature Gasoline Lottery Tickets Clothing Tobacco Products General store Other combination Grocery/gas station Grocery/bar Grocery/restaurant Gross sales reporting method: (Circle one) Actual Estimated* Hot Food Auto Parts Food Stamp Issuance page if needed Household supplies Liquor Hardware videos pharmacy etc ) List below Add I declare that I have examined this application including any accompanying schedules and statements and to the best of my knowledge and belief it is true correct and complete Signature of Taxpayer or Agent Title PhonePrint name Date If you are authorized to accept food stamps under the federal Food Stamp Act you do not need to file this application and obtain the New Mexico Retail Food Store Certificate to qualify to take the food deduction pursuant to Section 7 9 92 NMSA 1978 Maintain your Food Stamp Program authorization in your files IMPORTANT DEFINITIONS Food Any food or food product intended for human consumption except alcoholic beverages tobacco hot foods and hot food products prepared for immediate consumption Food also includes seeds and plants to grow foods for personal con sumption of households according to 7 USCA 2012(g)(1) Retail Food Store An establishment that sells food for home preparation and consumption For New Mexico purposes the establishment must meet the federal definition of retail food store in 7 USCA 2012(K)(1) for federal food stamp purposes whether or not it actually participates in the federal Food Stamp Program Stores or markets where staple sales make up less than 50% of gross receipts concessions sidewalk or open air vendors and vending machines do not qualify Do not include coffee tea cocoa carbonated and non carbonated drinks candy condiments and spices in the 50% Variety Enough items (no fewer than 3) in each of the staple food groups listed below to meet most people s food needs Staple Food (1) Bread rice pasta (2) dairy foods (3) fruits and vegetables and (4) meats (fresh packaged canned or frozen) Do not count hot foods prepared foods such as sandwiches or salads candy condiments spices coffee tea cocoa or carbonated or non carbonated drinks Perishable foods Fresh frozen or refrigerated food that could spoil in two or three weeks Location of records; physical address Medium or small grocery Motor Oil Beer/Wine Outdoor Equipment Other Services What are they? (Games Multi stall farmers market (application for multiple stalls) Specialty foods meat store fish store bakery etc Health/natural food store New Mexico Taxation and Revenue Department Nonprofit food buying co op Wholesaler Military commissary NOTE: All information submitted on this application is subject to verification by physical inspection Other food store Milk route Bread route P O Box 5374 ROSWELL: P O Box 8485 Albuquerque NM 87198 8485 Taxation & Revenue Department P O Box 607 Page 1 of 3 Page 2 of 3 PART 1 Business Information PART 2 Retail Store Operation Information PART 3 STAPLE FOOD STOCK PART 4 SALES INFORMATION Poultry/Fowl (chicken turkey etc) Meat (beef pork lamb etc ) Print store name (if different from business name) CRS identification number (if different) Print store name and chain unit number if applicable CRS identification number for store Print the business name CRS identification number FEIN or SSN Produce (fruits vegetables) Fish/Seafood Produce route Other route Produce stand (single store application) Qualifying as a retail food store: To qualify a retail store must meet at least one of two criteria the federal government sets It either must stock and offer a variety of foods on a continuous basis in each of four staple food categories two of which must be perishable foods or function as a specialty store attributing 50% or more of its gross retail sales to staple foods The terms food retail food store staple food and variety are defined in the federal Food Stamp Act of 1964 See these important definitions below Stores selling only accessory foods including spices candy soft drinks tea or coffee ice cream or dough nuts or bakeries not selling bread are ineligible These stores stores do not qualify to accept food stamps and therefore do not qualify as retail food stores for the gross receipts tax deducion in New Mexico Retail store information: Complete one application for each store location Rev 03/2005 Rev 03/2005 Roswell NM 88202 1557 RPD 41295 RPD 41295 New Mexico Taxation and Revenue Department Santa Fe NM 87502 5374 Telephone: 505/827 0951 Taxation & Revenue Department P O Box 1557 SANTA FE: Taxation & Revenue Department Telephone: 505/524 6225 Section A: Firms that carry a full line of groceries Complete this part if your store stocks on a continuous basis an ample variety of the types of foods listed below in each category Check Variety for each staple food category you sell in your store which meets the definition of variety (see instructions) Also check Perishable for each category which meets the definition of perishable (see the instructions) Staple Food Category Examples of staple food items Variety Perishable Bread/Cereals Bread cereals pasta grains rice flour Dairy Products Cheese butter milk yogurt Fruits/Vegetables All forms of fruits vegetables 100% juice (Include fresh frozen and canned) Meat/Poultry/Fish Beef chicken bacon ham shellfish sandwich meats (Include fresh frozen and canned) Section B: Firms with a specialty line of Staple Foods Check the box below if your business sells a limited variety or line of staple foods; for example a bakery milk route produce stand or meat market Stores selling only accessory foods do not qualify See Qualifying as a retail food store in the instructions Provide the annual retail food sales and the annual gross sales at this location that you reported for the same time period for Gross Sales in Part 4 (see below) for the past two years This may be an estimated figure Check if applicable: I am applying for New Mexico Retail Food Store Certification under Section B Street address Supermarket Telephone: 505/325 5049 Page 3 of 3 Telephone: 505/841 6200 Las Cruces NM 88004 0607 Who Must File This Form Effective January 1 2005 receipts of certain retail food stores from the sale of food intended for home consumption are deductible from gross receipts pursuant to Section 7 9 92 NMSA 1978 To qualify as a retail food store eligible to take the new deduction for sales of certain foods against gross receipts tax the establishment either must file this application for New Mexico Retail Food Store Certification or be currently authorized to accept food stamps under the federal Food Stamp Act A taxpayer who can accept food stamps under the federal Food Stamp Act is a retail food store for purposes of Section 7 9 92 NMSA 1978 for tax periods during which the taxpayer is authorized to accept food stamps Such a taxpayer does not require state certification to take the food deduction against gross receipts