State of New Mexico Taxation and Revenue Department ACD - 31096 REV. 03/00 DEPARTMENT USE ONLY A. Control log number B. Date Received TAX CLEARANCE REQUEST 1. Name of taxpayer for whom clearance is requested 2. NM Taxation & Revenue Dept. Identification Number 3. Doing Business as (if different than Item 1) 4. Federal ID Number 5. Street Address of Taxpayer 6. Mailing Address of Taxpayer (if different than Item 5) 7. City State 8. Contact Name and Title 9. Contact Telephone Number ( ) 10. Date Began Doing Business in N.M. 12a. Nature of business in New Mexico 13. Type of Request q 14. Check if Business: 11. Date Will Cease Doing Business in N.M. 12b. Basis for deductions from gross receipts, if any were taken. q q Successor in Corporate Liquor License Business Withdrawal/Dissolution Clearance 20. Check if any License/Permit will be: 15. Liquor License No. q Sold Gasoline / Special Fuel q Sold Liquor q Sold Cigarettes q Sold Tobacco Products q Severed Natural Resources q Processed Natural Resources q Sold Oil Zip Code q 16. Public Regulation Commission No. q Leased q Sold q Other _____________________ 17. Contractor's License No. q Check the Box in Item 15, 17, 18 or 19 to show which license/permit is to be transferred. 18. SCC Permit No. q q 21. Has Liquor License been leased previously? Yes (see reverse) 19. OGRID No. q q No IF BUSINESS/LICENSE/PERMIT IS TO BE OPERATED BY ANOTHER TAXPAYER GIVE NAME AND ADDRESS BELOW 22. Name of Purchaser/Lessee 23. NM Taxation & Revenue Dept. Identification Number 24. Doing Business as (if different than Item 21) 25. Telephone Number ( ) 26. Street Address 27. Mailing Address (if different than Item 25) 28. City State Zip Code I declare I have examined this request and all attachments and to the best of my knowledge and belief the information is true, correct and complete. 29. Printed or Typed Name 30. Position or Title 31. Company 32. Signature 33. Date American LegalNet, Inc. www.FormsWorkflow.com TAX CLEARANCE REQUEST - GENERAL INFORMATION AND INSTRUCTIONS Any purchaser or lessee of all or part of an existing business enterprise may request a tax clearance from the Department. Failure to request a tax clearance could subject the purchaser or lessee to liability for any taxes incurred and not paid by the seller or lessor prior to the date of the transfer. The Department has 30 days from the date a complete and accurate tax clearance request is received from a successor in business to either issue the requested clearance, notify the purchaser of the amount of tax due from the seller, or begin an audit to determine what amount of tax, if any, is due. If an audit is begun, the period for issuing the tax clearance or notice of taxes due is extended to 60 days. If the Department fails to respond within the required time period, the purchaser is released from the obligation imposed by Section 7-1-61 NMSA 1978 to withhold part or all of the purchase price to cover any unpaid taxes. A tax clearance request from other than a successor in business is not subject to the time limits above. Please allow at least 45 days for processing. lessor or purchaser/lessee or a properly designated agent of either. All applicable Items 1 through 21 should be completed for the entity seeking the tax clearance. Purchaser/lessee information should be provided in Items 22 through 28. No Tax Clearance Request that is incomplete, unsigned, or requested after the effective date of the transaction will be processed. THE FOLLOWING DOCUMENTS, AS APPLICABLE, MUST BE ATTACHED TO THIS REQUEST OR IT WILL BE CONSIDERED INCOMPLETE AND WILL NOT BE PROCESSED: 4 A copy of the signed purchase agreement; 4 A copy of the signed lease agreement; 4 A copy of the liquor license suspension(s) from Alcohol & Gaming Division; 4 A copy of previous lease agreements if Item 20 was answered YES; 4 Original document appointing another to serve as agent or authorized representative. The Tax Clearance Request may be initiated by the seller/ Please direct questions and completed request with attachments to : Taxation & Revenue Department Audit & Compliance Support Office P.O. Box 5557 Santa Fe, NM 87502-5557 (505) 827-0926 SUCCESSOR IN BUSINESS - STATEMENT OF PURCHASER I, ______________________________________________, verify that I am the Purchaser of the business named _________________________________________________________________. I request the Department to issue a Certificate stating that as of the __________ day of ____________________, 20 _____, I, as purchaser, am not liable for any taxes due to the Department by the Seller. I, as Purchaser, q have q have not placed in a trust account for the benefit of the Taxation and Revenue Department a sufficient amount of the purchase price to cover any tax due on account of the Seller. The Trust account is located at _____________________________________________ in the amount of $_____________________. I, Purchaser, will start business on the __________ day of ____________________, 20 _____, doing business as _________________________________________________________________ under New Mexico CRS Identification Number __________-____________________-00-__________. The business address is: Address City State Zip Code I declare that the statement above is true and correct to the best of my knowledge and belief. 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