) 
                                                                                                                                                                                                                                       ZIP Code

                                                                                                                                                                                                                                                                                                                                                                          Dollar Amount/Number of Shares 
                                                                                                                                                                                                                                                                                                                                                                                                              s listed on Report

                                                                                                                                                                                                                                                                                                                                                                                                             *

                                                                                                                                                                                                                                       State                     Contact Phone Number

                                                                                                                                                                                                                                                                                                                                                                                                              Owner’s Address (a

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Total Request for Reimbursement: $_______________
                                                                                                                                                                                                                                                                                                                                                                          Date Pd. to Owner/Acct. Reactivated

                                                                                                                                                                                                                                       City                                          Contact E-mail Address                           ) 

                                                                                                                                                                                                                                                                                                                                                                                                                                  Claimant’s Name & Address (if different than owner) 

          State of New Mexico - Taxation & Revenue Department                                                State of ________________ Report Year ________________ Report Total________________                                                                 Contact Name
                                                                                                                                                                                                                                                                                                                                      f aggregate-specify                                                     )                                                                                                                                                                                                                                      I, ______________________________, a dully authorized representative of the holder listed above, do hereby certify                                                                                                                          that the above listed funds, or other property 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 indem-                                                                                                                       nify 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_______________
                                                                           HOLDER'S REQUEST FOR REIMBURSEMENT

                                                                                                                                                                                                                                       Address
                                                                                                                                                                                                                                                                                                                                                                                                              exactly as on Report
                                                                                                                                                                                                                                                                                                                                      Acct. Reference No. (i

                                                                                                                                                                                                                                                                                                                                                                                                              Owner’s Name (

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      IF AMOUNT WAS REMITTED IN ERROR, ATTACH 
RPD-41206                                                     Rev. 03/2011                                                                                                                       PART I HOLDER INFORMATION             Holder Name               Tax ID#             Contact Fax Number     PART II CLAIM INFORMATION                       Property Code                                                                                                                                                     *                                                   A SEPARATE SHEET DETAILING THE ERROR PART III HOLDER CERTIFICATION                                                                                                                                                                                                                                                                                                                                                                      Sworn to and subscribed before me this                                                                                                                       ____________day of __________20__                                                                                                                                                                                                                                                                                                                                                                                                                                                           Notary:__________________________                                   My commission expires:____________