RPD-41359     New Mexico Taxation and Revenue Department
Rev.  2/3/2012
              Annual Statement of Pass-Through Entity Withholding
Tax Year                                                Pass-through entity’s federal identication number (FEIN)

Pass-through entity’s name, street address, city,       Pass-through entity’s CRS identication number
state, ZIP code and telephone number

                                                        Owner’s federal identication number
                                    Check if address is                                    Check one:           FEIN
                                    outside the U.S.                                                            SSN
Owner’s name, street address, city, state, ZIP code     New Mexico Net Income of the owner from the pass-through 
                                                        entity

                                                        New Mexico state tax withheld
                                    Check if address is 
                                    outside the U.S.
              Owners must attach this form to the New Mexico state income tax return to claim 
              the amount of tax withheld against personal income or corporate income tax due. 
RPD-41359     New Mexico Taxation and Revenue Department
Rev.  2/3/2012
              Annual Statement of Pass-Through Entity Withholding
Tax Year                                                Pass-through entity’s federal identication number (FEIN)

Pass-through entity’s name, street address, city,       Pass-through entity’s CRS identication number
state, ZIP code and telephone number

                                                        Owner’s federal identication number
                                    Check if address is                                    Check one:           FEIN
                                    outside the U.S.                                                            SSN
Owner’s name, street address, city, state, ZIP code     New Mexico Net Income of the owner from the pass-through 
                                                        entity

                                                        New Mexico state tax withheld
                                    Check if address is 
                                    outside the U.S.
              Owners must attach this form to the New Mexico state income tax return to claim 
              the amount of tax withheld against personal income or corporate income tax due. 
RPD-41359     New Mexico Taxation and Revenue Department
Rev.  2/3/2012
              Annual Statement of Pass-Through Entity Withholding
Tax Year                                                Pass-through entity’s federal identication number (FEIN)

Pass-through entity’s name, street address, city,       Pass-through entity’s CRS identication number
state, ZIP code and telephone number

                                                        Owner’s federal identication number
                                    Check if address is                                    Check one:           FEIN
                                    outside the U.S.                                                            SSN
                                                        New Mexico Net Income of the owner from the pass-through 
Owner’s name, street address, city, state, ZIP code     entity

                                                        New Mexico state tax withheld
                                    Check if address is 
                                    outside the U.S.
              Owners must attach this form to the New Mexico state income tax return to claim 
              the amount of tax withheld against personal income or corporate income tax due.