Form RPD-41344 Native American Veterans Income Tax Settlement Fund Claim Form

(1) December 31 of the year three years after the veteran separated from military service or (1) was a member of a New Mexico federally recognized Indian nation tribe or pueblo; (2) December 31 of the year three years after the year in which the New Mexico PIT was withheld from the active duty pay of the veteran (2) was a resident within the boundaries of the Indian member's or the member's spouse's reservation or pueblo grant or within the boundaries of lands held in trust by the United States for the benefit of the member or spouse or the member's or spouse's nation tribe or pueblo; and (3) had New Mexico personal income tax (PIT) withheld from his or her active duty military pay and the amount withheld: (a) has not already been refunded to the claimant or the claimant's representative; and (a) he or she has been appointed by a court as the personal representative of the (a) the value of the entire probate estate of the decedent wherever located less liens (b) a copy of that court appointment is attached (b) at least thirty (30) days have elapsed since the death of the decedent; and (b) cannot be claimed as a refund by filing a New Mexico PIT return because the period for filing a refund has expired under Section 7 2H 3 NMSA 1978 the applicable statute of limitations (c) the successor is entitled to the settlement payment or Alan Martinez Deputy Secretary and encumbrances does not exceed $30 000; Dates of residency decedent; and Department of Veterans Services Income Tax Settlement Fund Claim P O Box 2324 Santa Fe NM 87504 2324 Verification of Veteran's Status by the Department of Veterans Services (1) If the claimant is a successor who is not the surviving spouse of the deceased veteran a signed and dated notarized statement attesting that: (2) If the claimant is a personal representative a signed and dated notarized statement attesting that: (Continued on the next page ) (Page 1 of 3) (Page 2 of 3) (Page 3 of 3) Amount of New Mexico income tax withheld from the attached copy of Forms W2 Enter "Do not have W2" if you do not have a Form W2 for the year Box must be marked in order to qualify for settlement payment Branch of Service Check one Check the following two boxes to indicate the required documentation is attached City state and ZIP code Claimant: Copy of the death certificate or other proof of death (An original or an authentic copy of a telegram or letter from the Department of Defense notifying the next of kin of the decedent's death will constitute proof of death ) Proof of death must be attached if the veteran is deceased Current mailing address Give us the address where you currently receive your mail Dates of military service DD Form 214 is attached or Deceased Veteran: A claim for a settlement payment must be made by the eligible Native American veteran or in the case of a deceased veteran by the veteran s spouse other successor or personal representative (an executor administrator or anyone in charge of the deceased veteran s property) If the claim is being made for a deceased veteran the claim must be accompanied by a death certificate or other proof of death and by: during period of active duty military service Enter below each tax year in which New Mexico income tax was withheld and the amount of New Mexico income tax with held from active military service during the year and reported on the federal Form W2 Attach all federal Forms W2 If you do not have a copy of your federal Forms W2 or the attached federal Forms W2 do not represent all the tax withheld from active military service during a year check the box in the third column to request the Taxation and Revenue Department obtain the claimant's W2 Form information from the Department of Defense For each tax year listed complete the state ment in the fourth column Enter the branch of service and the dates of active duty in the Armed Forces of the United States To verify the active duty period attach Form(s) DD Form 214 and mark the box below indicating the form(s) is attached or mark the box to authorize the Department of Veterans Services to request a copy of the form from the Department of Defense FOR DEPARTMENT USE ONLY Form RPD 41083 Affidavit to Obtain Refund of New Mexico Tax Due a Deceased Taxpayer Complete Form RPD 41083 even if you were the spouse of the veteran at the time of death Form must be signed dated and notarized Form RPD 41083 can be downloaded from the Taxation and Revenue website at www tax newmexico gov Form RPD 41344 Native American Veterans Income Tax Settlement Fund Claim may be downloaded from the Taxation and Revenue Department website at www tax newmexico gov or from the Department of Veterans Services website at www dvs state nm us From To Home of record (physical address or description) I authorize the Department of Veterans Services to request a copy of the claimant's DD Form 214 from the Department of Defense I declare I have examined this application including accompanying schedules statements and attachments and to the best of my knowledge and belief it is true correct and complete I declare that the address(s) listed above is the home of record established for the claimant (veteran) with the Depart ment of Defense while in active duty military service I request the Taxation and Reve nue Department obtain the claim ant's Form W2 information for the tax year If only the spouse is an enrolled member of an Indian nation tribe or pueblo enter the spouse's name If the refund must be made payable to a person other than the veteran enter the name and SSN of the person entitled to claim the refund; otherwise the check will be made payable to the estate of the decedent Income Tax Settlement Fund Claim Income Tax Settlement Fund Claim Indicate the name of Indian nation tribe or pueblo in which the address is located INSTRUCTIONS Mail completed Form RPD 41344 Native American Veterans Income Tax Settlement Fund Claim and attachments to: Alan Martinez Deputy Secretary Department of Veterans Services P O Box 2324 Santa Fe NM 87504 2324 Telephone number is 866 433 8387 Mail the completed forms and attachments to: Mailing address Name of New Mexico federally recognized Indian nation tribe or pueblo of which the veteran or the veteran's spouse is an enrolled member Name of spouse other successor or personal representative (first middle last) Name of veteran (first middle last) Name of veteran as indicated on DD Form 214 if different NATIVE AMERICAN VETERANS NATIVE AMERICAN VETERANS NATIVE AMERICAN VETERANS Income Tax Settlement Fund Claim No claim for a settlement payment may be made after December 31 2012 Additionally no claim for a settlement payment can be made for an amount of withholding that can be claimed as a refund by filing a New Mexico PIT return A New Mexico PIT return can be filed by a Native American veteran to claim a refund by the later of: Part 1 Veteran's Information Part 2 Veteran's Status as a Native American Part 3 Military Service Part 4 Residency on Tribal Land During Period of Active Duty Part 5 Deceased Veteran Complete Part 5 only if the veteran is deceased Part 6 Continued Part 6 New Mexico Income Tax Withheld Part 7 Signature of Claimant Please complete this application for a settlement payment if you are a Native American Veteran who maintained a home on tribal land during your military service and had New Mexico income tax withheld on any of your active duty military pay Purpose of this Form: A claim for a settlement payment from the Native Americans Income Tax Settlement Fund may be made for any period of active duty in the armed forces of the United States during which the claim ant: Purpose of this Form: A claimant for a settlement payment from the Native American Veterans Income Tax Settlement Fund must substantiate residency on Indian nation tribe or pueblo land during the period(s) any New Mexico personal income tax was withheld from active duty military pay The veteran must be a resident within the boundaries of the Indian member's or the member's spouse's reservation or pueblo grant or within the boundaries of lands held in trust by the United States for the benefit of the member or spouse or the member's or spouse's nation tribe or pueblo If the address shown on the claimant s DD Form 214 is not on tribal land or the claimant cannot establish that the address is on tribal land or the address was not the claimant's address of record for the entire period for which the claim is being made the claimant must provide the following statement signed by the claimant q was not received q was not received q was not received q was not received q was received q was received q was received q was received q Yes q Yes q Yes q Yes RESIDENCY STATEMENT Rev 07/2010 RPD 41344 Secretary of Department of Veterans Services or delegate Print name Title Date Signature of veteran or if deceased personal representative or legal successor Print name Date Social security number Social security number State of New Mexico Department of Veterans Services State of New Mexico Department of Veterans Services State of New Mexico Department of Veterans Services Tax year The claimant's (or claimant's spouse's) home of record address for the entire period of the claimant's military service covered by this claim is located on the Indian nation tribe or pueblo to which the claimant or the claimant's spouse is a member The Department of Veterans Services has examined the veteran's information and has verified that the application including accompanying schedules statements and attachments is true correct and complete according to the records available to the Department The application is ready for review by the Taxation and Revenue Department The veteran's date of death To obtain a settlement payment you must complete this form and submit it to the New Mexico Department of Veterans Services with all required documentation To the best of my knowledge I certify that a refund for the taxes withheld (check only one box): Total of Column 2 Veteran's Information