ACD - 31096
REV.    01/14   State of New Mexico - Taxation and Revenue Department                            DEPARTMENT USE ONLY
                               AUDIT & COMPLIANCE DIVISION                              A. Control log number

                                                                                        B. Date Received
                REQUEST FOR TAX CLEARANCE

                                         SECTION     A
Name of Taxpayer for Whom Clearance is Requested                              NM Taxation & Revenue Dept. ID Number 

Doing Business as                                                             Federal ID Number

Street Address of Taxpayer

Mailing Address of Taxpayer

City                                                                 State                       Zip Code

Contact Name and Title                                                        Contact Telephone Number
                                                                              (        )
Date Began Doing Business in N.M.                   Date Will Cease Doing Business in N.M.

Nature of business in New Mexico

Type of Request        q   Successor in           q Corporate                        q           Liquor License 
                           Business                 Withdrawal/Dissolution                       Clearance
Check if Business:              Enter Number under Item below to show which 
                                license/permit is to be transferred.        Check if any License/Permit will be:
q Sold Gasoline / Special Fuel  Liquor License No.
q Sold Liquor                                                               q Leased   q Sold
q Sold Cigarettes               Secretary of State Corporation No.
q Sold Tobacco Products                                                     q Other _____________________
q Severed Natural Resources     Secretary of State Permit No.
                                                                            Has Liquor License been leased previously?
q Processed Natural Resources
                                OGRID No.
q Sold Oil                                                                  q Yes (see instructions)   q No

                                         SECTION     B
IF BUSINESS/LICENSE/PERMIT IS TO BE OPERATED BY ANOTHER TAXPAYER GIVE NAME AND ADDRESS BELOW
Name of Purchaser/Lessee                                                      NM Taxation & Revenue Department ID Number 

Doing Business as                                                             Telephone Number
                                                                                    (           )
Street Address

Mailing Address

City                                                                 State                       Zip Code

                       SECTION   C       MUST BE COMPLETED AND SIGNED
I declare I have examined this request and all attachments and to the best of my knowledge and belief the information is true, correct and complete.
Printed or Typed Name                    Position or Title                    Company

Signature                                                                                        Date

                                        REQUEST for TAX CLEARANCE

           GENERAL INFORMATION                                                       INSTRUCTIONS
Any purchaser or lessee of all or part of an existing business    The Tax Clearance Request may be initiated by the 
enterprise may request a tax clearance from the Depart-           seller/lessor or purchaser/lessee or a properly designated 
ment. Failure to request a tax clearance could subject the        agent of either. All applicable Items in Section A should be 
purchaser or lessee to liability for any taxes incurred and not   completed for the entity seeking the tax clearance. 
paid by the seller or lessor prior to the date of the transfer.   Purchaser/lessee information should be provided in Items 
                                                                  in Section B. No Tax Clearance Request that is incom-
The Department has 30 days from the date a complete               plete, unsigned, or requested after the effective date of 
and accurate  tax clearance  request is received  from a          the transaction will be processed.
successor in business to either issue the requested clear-
ance, notify the purchaser of the amount of tax due from          THE  FOLLOWING  DOCUMENTS,  AS  APPLICABLE, 
the seller, or begin an audit to determine what amount of         MUST BE ATTACHED TO THIS REQUEST OR IT WILL 
tax, if any, is due. If an audit is begun, the period for issuing BE  CONSIDERED  INCOMPLETE  AND WILL  NOT  BE 
the tax clearance or notice of taxes due is extended to  60       PROCESSED:
days. If the Department fails to respond within the required 
time period, the purchaser is released from the obligation        4  A copy of the signed purchase agreement;
imposed by Section 7-1-61 NMSA 1978 to withhold part or           4  A copy of the signed lease agreement;
all of the purchase price to cover any unpaid taxes.              4  A copy of the liquor license suspension(s) from 
                                                                     Alcohol & Gaming Division;
A tax clearance request from other than a successor in            4  A copy of previous Liquor License lease;
business is not subject to the time limits above. Please          4  Original document appointing another to serve as   
allow at least 45 days for processing.                               agent or authorized representative.

                                           Please direct          Taxation & Revenue Department
           questions and completed request                        Audit & Compliance Support Office 
                             with attachments to :                P.O. Box 5557 
                                                                  Santa Fe, NM  87502-5557
                                                                  (505)  827-0951

           SUCCESSOR IN BUSINESS - STATEMENT OF PURCHASER
I, ________________________________________________, verify that I am the Purchaser of the business named 
_______________________________________________. I request the Department to issue a Certificate stating 
that as of the __________ day of ____________________, 20 _____, I, as purchaser, am not liable for any taxes 
due to the Department by the Seller. I, as Purchaser,  q have  qhave not placed in a trust account for the benefit of 

the Taxation and Revenue Department a sufficient amount of the purchase price to cover any tax due on account of 
the Seller. The Trust account is located at _____________________________________________ in the amount of 
$_____________________. I, Purchaser, will start business on the __________ day of _________________, 20 _____,  
doing business as _________________________________________________________________ under New Mexico 
CRS Identification Number __________-____________________-00-__________. The business address is:

Address

City                                                                 State                          Zip Code

I declare that the statement above is true and correct to the best of my knowledge and belief.
Printed or Typed Name                                                                Title

Signature                                                                            Date