Form RPD-41358 Cancer Clinical Trial Tax Credit Claim Form

6) a qualified research entity that meets the crite ria established by the federal national institutes of health for grant eligibility; Cancer clinical trial means a clinical trial: Enter the number of patients who participated in a qualified cancer clinical trial under the claimant s supervision during the tax year Multiply line 2 times $1 000 but do not enter more than $4 000 This is the amount of tax credit that maybe claimed Rural New Mexico means a class B county in which no municipality has a population of 60 000 or more according to the most recent federal decennial census and includes the municipalities within that county This includes areas within New Mexico that are outside of Bernalillo DeBaca Dona Ana Los Alamos Sandoval San Juan and Santa Fe Counties that is being conducted with approval of at least one of the following: that is provided in this state as part of a scientific study 1 Last day of the tax year for this claim (Format for the date is mm/dd/yyyy) 1) one of the federal national institutes of health; 1) specific goals; 2) a federal national institutes of health cooperative group or center; 2) a rationale and background for the study; 3) criteria for patient selection; 3) the United States Department of Defense; 4) specific direction for administering the therapy or intervention and for monitoring patients; 4) the Federal Food and Drug Administration in the form of an investigational new drug application; 5) a definition of quantitative measures for determin ing treatment response; 5) a definition of quantitative measures for determining treatment response; 5) the United States Department of Veterans Affairs; 6) methods for documenting and treating adverse reactions; and 7) a reasonable expectation that the treatment will be at least as efficacious as standard cancer treat ment; 7) a reasonable expectation that the treatment will be at least as efficacious as standard cancer treatment CANCER CLINICAL TRIAL TAX CREDIT CLAIM FORM CANCER CLINICAL TRIAL TAX CREDIT CLAIM FORM Check all that apply: conducted for the purposes of the prevention of or the prevention of reoccurrence of cancer or the early detec tion or treatment of cancer for which no equally or more effective standard cancer treatment exists; Enter the name and contact information for the organization approving the cancer clinical trial Include the contact s name phone number and e mail address exists grant eligibility; Important Definitions in which the personnel conducting the clinical trial are working within their scope of practice experience and training and are capable of providing the clinical trial be cause of their experience training and volume of pa tients treated to maintain their expertise Instructions is needed continue the list on a separate page Owner s Share Mailing address if different than the physical address City state and ZIP code Expiration Date of MLN Name of contact Phone number E mail address Name of the qualified physician or the name of the practice SSN FEIN New Mexico CRS ID Number Name SSN MLN Expires of the Credit NOTE: Failure to attach this fully completed form to your New Mexico return will result in denial of the credit of a new therapy or intervention and is for the prevention of prevention of reoccurrence early detection treat ment or palliation of cancer in humans and in which the scientific study includes all of the following: Only a qualified licensed physician may claim the credit If the physician belongs to a business association in which one or more members qualifies for a cancer clinical trial tax credit the credit is to be equally apportioned between the eligible physicians conducting supervising or participating in the cancer clinical trial for which the credit is allowed If not apportioned equally provide an explanation in the space provided in Part III Section 2 The total cancer clinical trial tax credit allowed for all the members of a partnership or business association shall not exceed the amount of credit that could have been claimed by one qualified physician Page 1 of 2 Page 2 of 2 Part I Qualified physician or practice Part II Complete this section to compute the total credit amount allowed during the tax year On line 1 enter the last day of the tax year in which the cancer clinical trial was performed for this claim The format to be used for the date is mm/dd/yyyy On line 2 enter the number of patients who participated in a qualified cancer clinical trial under the claim ant s supervision during the tax year of the claim On line 3 multiply line 2 times $1 000 but not more than $4 000 and enter the amount of tax credit that may be claimed Part II Total credit amount allowed Part III Owners members or partners if the cancer clinical trial is performed within a partnership or business association Part III Section 1 This section is used to identify the owners members or partners eligible to claim the credit if the cancer clinical trial is performed within a partnership or business as sociation in which one or more members qualifies For each owner member or partner enter their name social security number medical license number the date their medical li cense expires and the owner member or partners share of the total credit allowed on line 3 Part II of this claim form Part III Section 2 If the credit is not evenly distributed to each member owner or partner listed in Section 1 enter the reason in Section 2 Part IV Complete Sections 1 and 2 affirming that the cancer clinical trial qualifies for the cancer clinical trial tax credit You must be able to answer yes to all of the questions listed and to provide a name and contact information for the organization that approved the cancer clinical trial Part IV Qualifying the cancer clinical trial pathophysiology and has a therapeutic intent; Physical address of clinic where the clinical trial took place City state and ZIP code Medical License Number (MLN) Section 1 If the cancer clinical trial is performed by a partnership or business association in which one or more members qualify because they are eligible physicians conducting supervising or participating in the cancer clinical trial for which the credit is allowed complete the following for each member partner or owner who is eligible to claim the credit If additional space Section 2 If the credit is not evenly distributed to each member partner or owner include an explanation in the space below If ad ditional space is needed continue the explanation on a separate page Section I Section II Sign and date the claim form affirming that the information provided is correct Signature of claimant Date State of New Mexico Taxation and Revenue Department State of New Mexico Taxation and Revenue Department that has been reviewed and approved by an institutional review board that has an active federal wide assurance of protection for human subjects; and that is considered part of a cancer clinical trial; that is not designed exclusively to test toxicity or disease The cancer clinical trial must meet all requirements in Section I below to qualify Check all boxes that apply In Section II you must provide the name of the organization and contact information for the entity approving the cancer clinical trial Enter that information in Section II below The cancer clinical trial was conducted for the purposes of: a) the prevention of or the prevention of reoccurrence of cancer or b) the early detection or treatment of cancer for which no equally or more effective standard cancer treatment The clinical trial has been reviewed and approved by an institutional review board that has an active federal wide assurance of protection for human subjects; and The clinical trial in which the personnel conducting the clinical trial are working within their scope of practice experi ence and training and are capable of providing the clinical trial because of their experience training and volume of patients treated to maintain their expertise The clinical trial is being conducted with approval of at least one of the following: 1) one of the federal national institutes of health; 2) a federal national institutes of health cooperative group or center; 3) the United States Department of Defense; 4) the Federal Food and Drug Administration in the form of an investigational new drug application; 5) the United States Department of Veterans Affairs; or 6) a qualified research entity that meets the criteria established by the federal national institutes of health for The clinical trial is considered part of a cancer clinical trial; The clinical trial is not designed exclusively to test toxicity or disease pathophysiology and has a therapeutic intent The clinical trial is provided in this state as part of a scientific study of a new therapy or intervention and is for the prevention of prevention of reoccurrence early detection treatment or palliation of cancer in humans and in which the scientific study includes all of the following: The purpose of the cancer clinical trial tax credit is to encour age physicians to participate as clinical trial investigators by performing cancer clinical trials of new cancer treatments in New Mexico and making cancer clinical trials more readily available to cancer patients in New Mexico To complete the form Part I Enter the information for the qualified physician or if a partnership or business association enter the informa tion for the partnership or business association in which the cancer clinical trials were conducted You must provide the physical address of the clinic to show where the cancer clinical trials were conducted Enter the qualified physician s medical license number and expiration date if the applicant is a physician If a partnership or business association leave these boxes blank and enter the medical license number and expiration date of each owner member or partner in Part III Section I Under penalty of perjury I declare that I have examined this claim and to the best of my knowledge and belief it is true correct and complete When claiming the cancer clinical trial tax credit this form must accompany the personal income tax or fiduciary income tax return to which the taxpayer wishes to apply the credit and mailed to the address on the tax return For assistance call 505 827 1746 Who May Claim This Credit: For tax years beginning on or after January 1 2012 but before January 1 2016 a taxpayer who files an individual New Mexico income tax return who is not a dependent of another taxpayer who is an oncologist that is a physician licensed pursuant to the Medical Practice Act (Section 61 6 1 NMSA 1978) and whose practice is located in rural New Mexico may claim a tax credit of $1 000 for each patient participating in a cancer clinical trial under the physician s supervision during the tax year but not to exceed $4 000 for all cancer clinical trials conducted by that physician The credit may only be claimed for the tax year in which the physician participates as an investigator in a clinical trial The credit may not be carried forward to another year or refunded This credit can only be claimed against personal income tax owed by the licensed physician A husband and wife who file separate returns for a tax year in which they could have filed a joint return may each only claim one half of the tax credit that would have been allowed on a joint return