Form RPD-41347 Application for Designation as a Qualified Intermediary

A qualified intermediary must not: A qualified intermediary shall by means of a sworn notarized statement notify the Taxation and Revenue Department of the transfer and of the date of the transfer within ten days of the transfer Credits shall only be transferred in increments of ten thousand dollars ($10 000) or more The qualified intermediary shall keep an account of the credits and have the authority Application for Designation as a Qualified Intermediary be a real estate broker or any person identified in Section 61 29 2 NMSA 1978 be an entity owned wholly or in part by one of the foregoing persons or be engaged in the practice as a certified public accountant as defined in Section 61 28B 3 NMSA 1978 By signing below you are attesting that you do not meet any of the criteria above and therefore meet the requirements as a qualified intermediary as set forth in Seciton 7 2 18 10 or 7 2A 8 9 NMSA 1978 employ any of the foregoing persons have been previously convicted of a felony have had a professional license revoked Mail to New Mexico Taxation and Revenue Department PIT Edit Error P O Box 5418 Santa Fe New Mexico 87504 5418 For assistance completing this form call (505) 476 3683 Mailing address City state and ZIP code may report to the Taxation and Revenue Department (TRD) a transfer of approved land conservation incentives tax credit Name of qualified intermediary Phone number E mail address Notary Public My commission expires of a credit to the Taxation and Revenue Department Purpose of this Form Qualified Intermediary: Rev 02/2011 RPD 41347 Signature of qualified intermediary Date State of New Mexico Taxation and Revenue Department Subscribed and sworn before me this day of 20 Sworn statement of qualified intermediary This form Application for Designation as a Qualified Intermediary must be used by a person eligible to be certified by the Department as a qualified intermediary for purposes of the Land Conservation Incentives Tax Credit Qualified intermediaries to another taxpayer This application must be signed by the qualified intermediary and notarized before reporting a transfer to issue sub numbers registered with the Taxation and Revenue Department and traceable to the original credit Under penalty of perjury I declare I have met the requirements as a qualified intermediary and am qualified to report the transfer of a land conservation tax credit as set forth in Section 7 2 18 10 or 7 2A 8 9 NMSA 1978 I declare that I have examined the information provided and attachments and to the best of my knowledge and belief it is true correct and complete