DR 1316 (09/20/21)
                                                      COLORADO DEPARTMENT OF REVENUE
                                                      Denver CO
*131316==19999*                                       Tax.Colorado.gov
                                                      Page 1 of 1

                         Colorado Source Capital Gain Affidavit 
This form must be completely and accurately filled out to avoid requests for additional information and/or delays in processing 
your return.
Taxpayer Last Name                                 First Name                       Middle Initial SSN or Colorado Account Number

Spouse Last Name (if applicable)                   First Name                       Middle Initial SSN or Colorado Account Number

Provide the following information for each asset that qualifies under the requirements of the Colorado capital gain subtraction. 
Include any assets that resulted in a capital loss. Attach federal schedules and/or detailed explanation if needed. Attach 
additional sheets if needed.
A. Provide a brief description of the nature of the capital gain(s). Include complete address of real property. 
1.                                                                   2.

B. If the gain is due to an installment sale, give the date of the original sale and attach a copy of federal 
   Form 6252 to this form.
Note: If the sale was prior to 1999, it does not qualify for the capital gain subtraction.
1.                                                                   2.

C. If the gain is being passed through from another entity, list the name and account number of the pass-through 
   entity and the length of time the taxpayer had ownership interest in the entity. 
1. Entity                                                            2. Entity

Account Number                   Ownership Interest (length of time) Account Number          Ownership Interest (length of time)

D. Additional Information (must be completed)
Note: When the sale of a sole proprietorship or business interest is treated as a sale of assets on the federal return, you 
must report the assets sold on this form (attach additional pages if necessary). Each asset must meet the capital gain 
subtraction requirements to qualify. Intangibles such as goodwill do not qualify.
   (a) Property    (b) Date Acquired               (c) Date Sold     (d) Sale Price       (e) Cost or           (f) Gain or loss
                        (mm/dd/yyyy)               (mm/dd/yyyy)                           other basis
1.
                                                                 $                  0 0 $             0 0 $                     0 0
2.
                                                                 $                  0 0 $             0 0 $                     0 0

3. Total Gain or (Loss)                                                                                       $                 0 0

4. Net Capital Gain or (Loss) as reported on federal Form 1040 or 1040-SR                                     $                 0 0
Maximum subtraction is $100,000 for tax years beginning on or after January 1, 2010
5.  Colorado Source Capital Gain Subtraction, enter lesser of lines 3, 4, or $100,000 for tax years beginning 
   on or after January 1, 2010. Enter here and on the DR 0104AD, DR 0105, DR 0106, or DR 0112.                $                 0 0
Qualifying Colorado Source Capital Gains and Losses
I attest that the taxpayer(s) shown above has no overdue state tax liabilities and is not in default on any contractual 
obligations owed to the state or to any local government within Colorado at the time the attached income tax return is 
being filed. Under penalties of perjury, I declare that to the best of my knowledge and belief, this affidavit is true, correct 
and complete.
Signature, Taxpayer or Duly Authorized Individual                                                             Date (MM/DD/YY)

Spouse Signature (if joint return, both must sign)                                                            Date (MM/DD/YY)

                        Include a copy of federal Schedule D and/or Form 4797 with this form.