New Mexico Cancer Clinical Trial Tax Credit

Cancer Clinical Trial Tax Credit
Form RPD-41358 (Obsolete)
State of New Mexico - Taxation and Revenue Department

RPD-41358
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 physician 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

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

Name of contact

Phone number

Part II - Total credit amount allowed

FEIN

New Mexico CRS ID Number

E-mail address

1. Last day of the tax year for this claim
(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.

1.

$

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 additional space is needed, continue the explanation on a separate page.
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

State of New Mexico - Taxation and Revenue Department

RPD-41358
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
Int. 07/02/2015

State of New Mexico - Taxation and Revenue Department

CANCER CLINICAL TRIAL TAX CREDIT CLAIM FORM
Instructions

The purpose of the cancer clinical trial tax credit is to encourage physicians to participate as clinical trial investigators by
performing cancer clinical trials of new cancer treatments in
New Mexico and making cancer clinical trials more readily
available to cancer patients in New Mexico.
To complete the form
Part I. Enter the information for the qualified physician, or
if a partnership or business association, enter the information for the partnership or business association, in which
the cancer clinical trials were conducted. You must provide
the physical address of the clinic, to show where the cancer
clinical trials were conducted. Enter the qualified physician’s
medical license number and expiration date if the applicant
is a physician. If a partnership or business association, leave
these boxes blank and enter the medical license number and
expiration date of each owner, member or partner in Part III,
Section I.
Part II. Complete this section to compute the total credit
amount allowed during the tax year. On line 1, enter the
last day of the tax year in which the cancer clinical trial was
performed for this claim. The format to be used for the date
is mm/dd/yyyy. On line 2, enter the number of patients who
participated in a qualified cancer clinical trial under the claimant’s supervision during the tax year of the claim. On line 3,
multiply line 2 times $1,000, but not more than $4,000 and
enter the amount of tax credit that may be claimed.
Part III, Section 1. This section is used to identify the owners,
members or partners eligible to claim the credit if the cancer
clinical trial is performed within a partnership or business association in which one or more members qualifies. For each
owner, member or partner, enter their name, social security
number, medical license number, the date their medical license expires and the owner, member or partners share of
the total credit allowed on line 3, Part II of this claim form.
Part III, Section 2. If the credit is not evenly distributed to
each member, owner or partner listed in Section 1, enter the
reason in Section 2.
Part IV. Complete Sections 1 and 2 affirming that the cancer
clinical trial qualifies for the cancer clinical trial tax credit. You
must be able to answer yes to all of the questions listed, and
to provide a name and contact information for the organization
that approved the cancer clinical trial.
Sign and date the claim form affirming that the information
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 detection 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

•	

•	

•	
•	
•	

pathophysiology and has a therapeutic intent;
that 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;
that 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;
that is considered part of a cancer clinical trial;
that has been reviewed and approved by an institutional
review board that has an active federal-wide assurance
of protection for human subjects; and
in which the personnel conducting the clinical trial are
working within their scope of practice, experience and
training and are capable of providing the clinical trial because of their experience, training and volume of patients treated to maintain their expertise.

“Rural New Mexico” means a class B county in which no
municipality has a population of 60,000 or more according
to the most recent federal decennial census and includes
the municipalities within that county. This includes areas
within New Mexico that are outside of Bernalillo, DeBaca.
Dona Ana, Los Alamos, Sandoval, San Juan, and Santa Fe
Counties.