Form RPD-41326 Rural Health Care Practitioner Tax Credit

Eligible health care practitioner means: (a) a certified nurse midwife licensed by the board of nursing as a registered nurse and licensed by the public health division of the New Mexico Department of Health to practice nurse midwifery as a certified nurse midwife; (b) a dentist or dental hygienist licensed pursuant to the Dental Health Care Act; (c) an optometrist licensed pursuant to the provisions of the Optometry Act; (d) an osteopathic physician licensed pursuant to the provisions of Chapter 61 Article 10 NMSA 1978 or an osteopathic physician assistant licensed pursuant to the provisions of the Osteopathic Physicians Assistants Act; (e) a physician or physician assistant licensed pursuant to the provisions of Chapter 61 Article 6 NMSA 1978; (f) a podiatrist licensed pursuant to the provisions of the Podiatry Act; (g) a clinical psychologist licensed pursuant to the provisions of the Professional Psychologist Act; and (h) a registered nurse in advanced Health care underserved area means a geographic area or practice location in which it has been determined by the New Mexico Practice site means a private practice public health clinic hospital public or private nonprofit primary care clinic or other health care Rural means an area or location identified by the New Mexico Department of Health as falling outside of an urban area Social security numberName of taxpayer (a) Tax year of credit approved for prior year (b) Certification number (c) Amount of credit approved (d) Credit applied to prior year returns (e) Unused credit avail able for carry forward [(c) (d)] (a) Tax year of credit approved in prior year Enter the tax year for each credit approved for a previous tax year Do (b) Certification number For each rural health care practitioner tax credit approved by NMDOH listed in column (a) 1 Enter the beginning and ending date of the tax year of this claim 2 Enter the amount of the rural health care practitioner tax credit allowed A taxpayer who has both a carry forward credit amount and a new credit amount derived from a credit approved for the cur Amount of credit approved For each tax credit listed enter the amount of credit approved for the tax year anesthetists and clinical nurse specialists as certified by NMDOH for the current tax year Attach the NMDOH certifcate of eligibility Before an eligible health care practitioner may claim the rural health care practitioner tax credit the practitioner shall submit an application to the New Mexico Department of Health (NMDOH) that describes the practitioner s clinical practice and contains additional information that NMDOH may require NMDOH will determine whether an eligible health care practitioner qualifies for the rural health care practitio ner tax credit and will issue a certificate to each qualifying eligible health care practitioner To apply for certification of eligibility contact care services are not being provided City state and ZIP code Credit applied to prior year returns For each credit amount listed in column (c) enter the total amount of credit applied to prior year personal income taxes due Department of Health through the use of indices and other standards set by the New Mexico Department of Health that sufficient health dependent of another individual who is an eligible health care practitioner and who has provided health care services in New Mexico in a rural health care underserved area in a tax year may claim a credit against personal income tax liability Enter the carry forward total of unused credit from previous years Attach the worksheet Schedule A enter the certification number from the certificate of eligibility issued by NMDOH Enter the sum of column (e) on line 3 on Enter the sum of lines 2 and 3 This is the total credit available in the current tax year For assistance completing this form or claiming the credit call (505) 476 3683 From to function beyond the scope of practice of professional registered nursing including certified nurse practitioners certified registered nurse health care practitioner tax credit eligible to be carried forward from prior years HOW TO CLAIM THIS CREDIT: Compute the credit amount on the worksheet below and submit this Form RPD 41326 Rural Health Care Practitioner Tax Credit Claim Form with the New Mexico personal income tax return during the tax year the credit is certified by NMDOH or the tax year in which a carry forward is claimed against a personal income tax liability During the tax year the credit is certified by NMDOH you must also submit a copy of the certificate of eligibility issued by NMDOH Include Schedule A if you have unused rural IMPORTANT DEFINITIONS Include Schedule A to Form RPD 41326 Rural Health Care Practitioner Tax Credit Claim Form if you have unused rural health care practitioner tax credit eligible to be carried forward from prior years Mailing address NMDOH at (505) 841 5817 or visit their web site at http://www health state nm us/care html The address is 300 San Mateo NE Suite 900 Albuquerque New Mexico 87108 not enter a credit approved for the current tax year claimed on line 2 of the first page of Form RPD 41326 Do not enter a credit if the certificate of eligibility is for a tax year more than three years from the tax year of this claim or if of the credit claimed exceeds a taxpayer s tax liability for the tax year in which the credit is being claimed the excess may be carried forward for three consecutive tax years practice who has been prepared through additional formal education as provided in Sections 61 3 23 2 through 61 3 23 4 NMSA 1978 to rent tax year shall apply the unused credit available from the oldest approved credit first RURAL HEALTH CARE PRACTITIONER TAX CREDIT CLAIM FORM Schedule A service location in a health care underserved area sician assistants certified nurse midwives certified registered nurse anesthetists and clinical nurse specialists who qualify If the amount Signature of Taxpayer or Agent Title Date State of New Mexico Taxation & Revenue Department State of New Mexico Taxation and Revenue Department Tax years beginning prior to January 1 2007 are NOT eligible the credit was not approved by NMDOH Unused credit may only be carried forward for three years following the tax year for which the credit was approved the first page of this form The rural health care practitioner tax credit may be claimed and allowed in an amount up to $5 000 for all eligible physicians osteopathic physicians dentists clinical psychologist podiatrists and optometrists who qualify and up to $3 000 for all eligible dental hygienists phy To qualify for the rural health care practitioner tax credit an eligible health care practitioner shall have provided health care during a tax year for at least 2 080 hours at a practice site located in an approved rural health care underserved area An eligible rural health care practitioner who provides health care services for at least 1 040 hours but less than 2 080 hours at a practice site located in an approved rural health care underserved area during a tax year is eligible for one half of the credit amount TOTAL Carry forward available Under penalty of perjury I delare I have examined this claim including accompanying returns schedules and statements and to the best of my knowledge and belief it is true correct and complete Unused credit available for carry forward Subtract column (d) from column (c) Enter the sum of all amounts in column (e) on line 3 of the current year claim form RPD 41326 WHO MUST FILE THIS FORM: Effective January 1 2007 a taxpayer who files a New Mexico personal income tax return who is not a Worksheet to calculate the total unused credit available for carry forward from prior years