DR 1319 (07/23/13) 
COLORADO DEPARTMENT OF REVENUE                                                            *131319==19999*
Denver, CO  80261-0005
www.TaxColorado.com

                                  Child Care Contribution Tax Credit 
                             Grandfathered Organization Application
Organization Name                                                                         Telephone Number
                                                                                          (    )
License Number or DOR Registration Number                   FEIN

Address                                   City                                                                                       State Zip

List the specific eligible programs for which the organization accepted qualifying donations for the child care contribution credit. 

Did the programs listed above include children ages 13-17?                       Yes    No
If yes, briefly explain

Provide a list of donors who claimed the credit during tax years 1999 to 2003. 

Attach copies of brochures, newspaper articles, community publications and other documentation to support the 
information on eligible programs listed above. Attach additional pages if needed. 
Name of Organization Officer                                Title

Signature of Organization Officer                                                         Date (MM/DD/YY)