RPD-41205
Rev. 03/23/2022   State of New Mexico - Taxation & Revenue Department
                  Unclaimed Property Office
                  P.O. Box 25123
                  Santa Fe, New Mexico 87504-5123
                  505-827-0668

                  HOLDER'S NEGATIVE REPORT

Name of Holder

Address

City                                             State               ZIP Code

Federal ID Number                          Telephone Number
                                           (       )
E-mail Address

The above named holder has no unclaimed property to file with the State of New 
Mexico for the ____________ Annual Report Year of the Period Ending June 30, 
____________.

I declare that I have examined this report and, to the best of my knowledge and 
belief, it is true, correct and complete.

Printed Name                                     Title

Signature                                        Date