RPD-41054                                     STATE OF NEW MEXICO
Rev. 06/2022
                           TAXATION AND REVENUE DEPARTMENT
                                  WC-1 - WORKERS' COMPENSATION FEE FORM

WHO MUST FILE: Every employer who is covered by the Workers' Compensation Act, whether by requirement or election, must file and 
pay the New Mexico Workers' Compensation Fee and file Form WC-1. See the instructions for requirements.

*IMPORTANT: On Line 1, enter the number of workers (employees) to whom the Workers' Compensation Fee applies. This is the number 
of covered employees you employed on the last working day of the calendar quarter. If you have no covered employees, enter zero. 

WHEN TO FILE: The Workers' Compensation Fee is due on or before the last day of the month following the close of the report period. 
A report period is a calendar quarter ending March 31, June 30, September 30 and December 31. 

Upon completion of this form, sign, date and enter your phone number and E-mail address on the form. Make the check or money order 
payable to Taxation and Revenue Department. 

Mail the bottom portion of this form with payment to New Mexico Taxation and Revenue Department, P.O. Box 2527, Santa 
Fe, NM 87504-2527. Retain the top portion for your records. For assistance call (505) 827-0832.

                                                                REPORT PERIOD:
A.  FEIN:                                                                             Beginning (mm-dd-yy) Ending (mm-dd-yy)

B.  NMBTIN:
                                                                1. *Number of covered   
                                                                     workers at close of  
C.  EAN:                                                           report period               1.
 NAME:
                                                                2. Assessment fee              2. $
 STREET/BOX:                                                    3.  Penalty                    3. $
                                                                4.  Interest                   4. $
 CITY, STATE, ZIP:
                                                                5.  Total due                  5. $

            PLEASE CUT AND INCLUDE THE BOTTOM PORTION WITH YOUR PAYMENT  
                              RETAIN THE UPPER PORTION FOR YOUR RECORDS 

WORKERS' COMPENSATION FEE (WC-1)

                                                                REPORT PERIOD:
A.  FEIN:                                                                             Beginning (mm-dd-yy) Ending (mm-dd-yy)

B.  NMBTIN:
                                                                1. *Number of covered 
                                                                     workers at close of 
C.  EAN:                                                             report period             1.
 NAME:
                                                                2. Assessment fee              2. $

 STREET/BOX:                                                    3.  Penalty                    3. $
                                                                4.  Interest                   4. $
 CITY, STATE, ZIP:
                                                                5.  Total due                  5. $
                                                                                                           Check if amended

Signature ___________________________________  Phone ______________ Date _____________ E-mail address __________________________
            Mail to:   Taxation and Revenue Department, P.O. Box 2527, Santa Fe, NM 87504-2527             WKC