RPD-41206
Rev. 02/27/2024                              New Mexico Taxation and Revenue Department
                                             Holder's Request For Reimbursement
                                                                             Unclaimed Property Office 
                                                                             P.O. Box 25123 
                                                                             Santa Fe, New Mexico 87504-5123
Page No ________ of ________

Section 1
1. Name of Holder                                                            2. Report Year                                  3.        FEIN, SSN, or ITIN

4. Mailing Address - City, State, Zip Code

5. Name of Contact Person                 6. Contact Phone Number            7. Contact Email Address

Section 2
If amount was remitted in error, attach a separate sheet detailing the error.
                Column 1                     Column 2                        Column 3                  Column 4 Column 5     Column 6  Column 7     Column 8        Column 9
         Owner's Name and Address            Claimant’s Name and Address     Property  Account Refer-           Date Paid    Dollar    Total       Type of Check    Amount 
                (Exactly as on report)       (If different than owner)       Type           ence Number         to Owner or  Amount/   Request for (Mark only one)  Remitted in 
                                                                             Code           (If aggregate       Date Account Number    Reimburse-                   Error (Mark 
                                                                                                       specify) Reactivated  of Shares ment
                                                                                                                                                                    only One)

                                                                                                                                                   c     Standalone c     Yes
                                                                                                                                                   c     Combined   c     No
                                                                                                                                                   c     Standalone c     Yes
                                                                                                                                                   c     Combined   c     No
                                                                                                                                                   c     Standalone c     Yes
                                                                                                                                                   c     Combined   c     No
                                                                                                                                                   c     Standalone c     Yes
                                                                                                                                                   c     Combined   c     No
                                                                                                                                                   c     Standalone c     Yes
                                                                                                                                                   c     Combined   c     No
                                                                                                                                                   c     Standalone c     Yes
                                                                                                                                                   c     Combined   c     No
                                                                                            Total of Column 7 to be issued as a combined check

                                                                                                                             Total of All Pages

RPD-41206
Rev. 02/27/2024                        New Mexico Taxation and Revenue Department
                                       Holder's Request For Reimbursement
                                                       Instructions

Section 3: Holder Certification

I                                                      , a dully authorized representative of the holder listed above, do her-
eby certify that the funds, or other property listed on all pages of the included with this certification which was listed in the Report filed by the holder, 
have been paid to the rightful owner(s) or their appointed representatives. I agree, upon payment of the above-described property to indemnify the State 
and hold it harmless for all claims and losses, demands, costs, and other expenses which the State may sustain by reason of returning property to the 
holder and by reason further of its refusal to pay the property to other person or persons.

Name and Title of Holder Representative (type or print)

Signature of Holder Representative                                                         Date

State of 

County of 

Sworn to and subscribed before me this                 day of                              20

Notary Signature                                                                           My commission expires

                                                                                           (Official Stamp)

RPD-41206
Rev. 02/27/2024                      New Mexico Taxation and Revenue Department
                                     Holder's Request For Reimbursement
                                                    Instructions
This form is used to request a reimbursement, or refund, or                     Period and Property Type Codes Schedule. The 
both for amounts that were submitted in error or amounts that                   number to the right of the property type indicates 
have been paid to the owner by holder.                                          the number of years of inactivity after which the 
                                                                                account should be reported as unclaimed.
In the reimbursement process, a holder decides to pay an              Column 4:  Account Reference Number
owner and then files a claim with the Unclaimed Property                        Enter account reference number. If aggregate-
Office (UPO) for reimbursement. We encourage the holder                         specify.
to use the reimbursement process for those customers and              Column 5: Date Paid to Owner or Date Account Reacti-
owners demanding immediate payment or reinstatement of                          vated
their accounts. The UPO makes every effort to respond to                        Enter the date that the amount was paid to owner 
your request as quickly as possible.                                            or the date the account was reactivated.
                                                                      Column 6: Dollar Amount/Number of Shares
Refunds are made to holders who have overpaid their un-                         Enter the dollar amount and/or the number of 
claimed property reports.  The overpayments are usually                         shares.
due to accounting errors or other mistakes made during the            Column 7: Total Request for Reimbursement
preparation of reports.                                                         Enter the total amount of reimbursement for row. 
                                                                      Column 8: Type of Check
Page Number Pages should be numbered consecutively                              Mark only one box in this column for each row.  If 
(e.g., page 1 of  24; 2 of 24) at the top of the form. Page                     holder is requesting a single check for the amount 
totals of amounts for a combined check, column 7 are to be                      in row mark Standalone. If holder is requesting 
entered on each page and the grand total should be entered                      a combined check for multiple rows mark Com-
on the last page.                                                               bined, then total at the bottom of the page. 
                                                                      Column 8: Amount Remitted in Error
FORM INSTRUCTIONS                                                               Mark only one box in this columns for each row. 
                                                                                If the amount was remitted in error mark yes and 
Section 1                                                                       attach a separate sheet detailing the error. If the 
1.  Name of Holder                                                              amount was not remitted in error mark no. 
   Enter the name of the holder.
2.  Report Year                                                       Section 3
   Enter the report year applicable to this report.                   Complete this section of the form which is a sworn statement 
3.  FEIN, SSN, or ITIN                                                by the holder or holders representative indicating that the 
   Enter the FEIN, SSN, or ITIN of the holder.                        statement is accurate, and that all other information provided 
4.  Mailing Address - City, State, Zip Code                           in the report is true and correct to the best of the holders' or 
   Enter the mailing address of the holder.                           holder's representative's knowledge. 
5.  Name of Contact Person
   Enter contact person's name.                                       You may photocopy this form as needed.
6.  Contact Phone Number
   Enter contact person's phone number.                               If you have any questions please contact the Unclaimed 
7.  Contact Email                                                     Property Office at:
   Enter contact person's email address.
                                                                       New Mexico Taxation & Revenue Department
Section 2                                                                       Unclaimed Property Office
Column 1:  Owner's Name and Address                                                      P.O. Box 25123
                List alphabetically. Enter owner’s last name, first             Santa Fe, New Mexico 87504-5123
                name, middle name or initial; and address. Use                  Unclaimed.Property@tax.nm.gov
                one block for each owner’s name and address. If                           505-827-0668
                there is joint ownership of the securities, list both 
                names within the same block. 
Column 2:  Claimant’s Name and Address
                If claimant is different than owner enter claimant's 
                last name, first name, middle name or initial; and 
                address; 
Column 3:  Property Type Code
                Enter the proper property type code correspond-
                ing to the description as listed on the Retention