RPD-41358                                      State of New Mexico - Taxation and Revenue Department
Int. 07/02/2015
                CANCER CLINICAL TRIAL TAX CREDIT CLAIM FORM
                                                               Page 1 of 2
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 physi-
cian 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. Married individuals 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.
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. 
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.

Part I - Qualified physician or practice
Name of the qualified physician or the name of the practice        SSN                          FEIN                                                New Mexico CRS ID Number

Physical address of clinic where the clinical trial took place     City, state and ZIP code                                                         Medical License Number (MLN)

Mailing address, if different than the physical address            City, state and ZIP code                                                         Expiration Date of MLN

                                                                   Phone number                                                  E-mail address
Name of contact                                                                                                                   

Part II - Total credit amount allowed
                                                               1. Last day of the tax year for this claim                                    1.
                                                                   (Format for the date is mm/dd/yyyy)
2. Enter the number of patients who participated in a qualified cancer clinical trial under 
   the claimant’s supervision during the tax year.  ...............................................................               2.

3. Multiply line 2 times $1,000, but do not enter more than $4,000. This is the amount of 
   tax credit that maybe claimed. .........................................................................................       3.         $

Part III - Owners, members or partners, if the cancer clinical trial is performed within a partnership or business association
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 
is needed, continue the list on a separate page.                                                                                                       Owner’s Share
                                           Name                                              SSN                              MLN            Expires            of the Credit
a.             ______________________________________   _______________   ____________  _____________$_____________

b.             ______________________________________   _______________   ____________  _____________$_____________

c.             ______________________________________   _______________   ____________  _____________$_____________

d.             ______________________________________   _______________   ____________  _____________$_____________

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.
________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

RPD-41358                            State of New Mexico - Taxation and Revenue Department
Int. 07/02/2015
                      CANCER CLINICAL TRIAL TAX CREDIT CLAIM FORM
                                                             Page 2 of 2
Part IV - Qualifying the cancer clinical trial
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.

Section I
Check all that apply:
‰         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 
               exists.
‰         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:
               1) specific goals; 
               2) a rationale and background for the study; 
               3) criteria for patient selection; 
               4) specific direction for administering the therapy or intervention and for monitoring patients; 
               5) a definition of quantitative measures for determining treatment response; 
               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 treatment.
‰         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  
                   grant eligibility;
‰         The clinical trial is considered part of a cancer clinical trial;

‰         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.

Section II

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.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

NOTE: Failure to attach this fully completed form to your New Mexico return will result in denial of the credit.
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.   

Signature of claimant                                                      Date 

RPD-41358              State of New Mexico - Taxation and Revenue Department
Int. 07/02/2015
                       CANCER CLINICAL TRIAL TAX CREDIT CLAIM FORM
                                                    Instructions
The purpose of the cancer clinical trial tax credit is to encour-        pathophysiology and has a therapeutic intent;
age physicians to participate as clinical trial investigators by  •      that is provided in this state as part of a scientific study 
performing cancer clinical trials of new cancer treatments in            of a new therapy or intervention and is for the prevention 
New Mexico and making cancer clinical trials more readily                of,  prevention  of  reoccurrence,  early  detection,  treat-
available to cancer patients in New Mexico.                              ment or palliation of cancer in humans and in which the 
                                                                         scientific study includes all of the following: 
To complete the form                                                     • 1) specific goals; 
Part I. Enter the information for the qualified physician, or            • 2) a rationale and background for the study; 
if a partnership or business association, enter the informa-             • 3) criteria for patient selection; 
tion for the partnership or business association, in which               • 4) specific direction for administering the therapy or 
the cancer clinical trials were conducted. You must provide                intervention and for monitoring patients; 
the physical address of the clinic, to show where the cancer             • 5) a definition of quantitative measures for determin-
clinical trials were conducted. Enter the qualified physician’s            ing treatment response; 
medical license number and expiration date if the applicant              • 6)  methods  for  documenting  and  treating  adverse 
is a physician. If a partnership or business association, leave            reactions; and 
these boxes blank and enter the medical license number and               • 7) a reasonable expectation that the treatment will 
expiration date of each owner, member or partner in Part III,              be at least as efficacious as standard cancer treat-
Section I.                                                                 ment;
                                                                       • that is being conducted with approval of at least one of 
Part II. Complete this section to compute the total credit               the following: 
amount allowed during the tax year. On line 1, enter the                 • 1) one of the federal national institutes of health; 
last day of the tax year in which the cancer clinical trial was          • 2) a federal national institutes of health cooperative 
performed for this claim. The format to be used for the date               group or center; 
is mm/dd/yyyy. On line 2, enter the number of patients who               • 3) the United States Department of Defense; 
participated in a qualified cancer clinical trial under the claim-       • 4) the Federal Food and Drug Administration in the 
ant’s supervision during the tax year of the claim. On line 3,             form of an investigational new drug application; 
multiply line 2 times $1,000, but not more than $4,000 and               • 5) the United States Department of Veterans Affairs; 
enter the amount of tax credit that may be claimed.                        or 
                                                                         • 6) a qualified research entity that meets the crite-
Part III, Section 1. This section is used to identify the owners, 
                                                                           ria established by the federal national institutes of 
members or partners eligible to claim the credit if the cancer 
                                                                           health for grant eligibility;
clinical trial is performed within a partnership or business as-
                                                                       • that is considered part of a cancer clinical trial;
sociation in which one or more members qualifies. For each 
                                                                       • that has been reviewed and approved by an institutional 
owner, member or partner, enter their name, social security 
                                                                         review board that has an active federal-wide assurance 
number, medical license number, the date their medical li-
                                                                         of protection for human subjects; and 
cense expires and the owner, member or partners share of 
                                                                       • in which the personnel conducting the clinical trial are 
the total credit allowed on line 3, Part II of this claim form.
                                                                         working within their scope of practice, experience and 
Part III, Section 2. If the credit is not evenly distributed to          training and are capable of providing the clinical trial be-
each member, owner or partner listed in Section 1, enter the             cause  of  their  experience,  training  and  volume  of  pa-
reason in Section 2.                                                     tients treated to maintain their expertise.
                                                                       “Rural New Mexico” means a class B county in which no 
Part IV. Complete Sections 1 and 2 affirming that the cancer           municipality has a population of 60,000 or more according 
clinical trial qualifies for the cancer clinical trial tax credit. You to the most recent federal decennial census and includes 
must be able to answer yes to all of the questions listed, and         the  municipalities  within  that  county.  This  includes  areas 
to provide a name and contact information for the organization         within New Mexico that are outside of Bernalillo, DeBaca. 
that approved the cancer clinical trial.                               Dona Ana, Los  Alamos, Sandoval, San Juan, and Santa Fe 
Sign and date the claim form affirming that the information            Counties.
provided is correct.

Important Definitions
“Cancer clinical trial” means a clinical trial:
• 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; 
• that is not designed exclusively to test toxicity or disease