DR 0375 (10/19/22)
                                                    COLORADO DEPARTMENT OF REVENUE
                                                    Tax.Colorado.gov
=DO=NOT=SEND=

   Instructions for Credit for Employer Paid Leave of Absence 
                           for Live Organ Donation Affidavit

You must complete this form and file it with your income                  The amount of credit allowed is 35% of your expenses, as 
tax return to claim the credit for employer paid leave of                 defined in statute, incurred during the tax year. 
absence for live organ donation. Please carefully read all of 
                                                                          You may not claim a tax credit related to a leave of 
the instructions, fully fill out the form, and submit it with your 
                                                                          absence period for an employee who you pay eighty 
income tax return. Keep the requested documentation to 
                                                                          thousand dollars, or more, in wages during the income tax 
substantiate credit claims.
                                                                          year.
In order to qualify for this credit, you must have:                       If the amount of credit allowed in the income tax year 
                                                                          exceeds your tax liability for that income tax year, you 
   •  Been a taxpayer as defined in section                               may carry forward and apply the unused credit against the 
                        1
   39-22-540, C.R.S.                                                      income tax due in each of the next five income tax years.
   •  Incurred expenses during the tax year:
                                                                          Upon request of the department of revenue as part of an 
    
                                                                          audit, you (as the employer) must provide the department 
     ○ By paying an employee during his or her 
      leave of absence period , and2                                      with documentation from the employee’s medical provider, 
                                                                          which you received from the employee, that verifies the 
     ○ For the cost of temporary replacement                              employee’s organ donation. If you cannot provide the 
    help, if any, during an employee’s leave                              documentation, then you are ineligible for the credit. Please 
    of absence period.                                                    keep this documentation with your records.

1 “Taxpayer” means an employer that deducts and withholds amounts 
   from the wages paid to a qualified employee pursuant to section  
   39-22-604(3), C.R.S. 
2  “Leave of absence period” means the period, not exceeding ten working 
   days or the hourly equivalent of ten working days per employee, during 
   which a taxpayer provides a paid leave of absence to an employee for 
   the purpose of organ donation. The term does NOT include a period 
   during which an employee utilizes any annual leave or sick days that 
   the employee has been given by the employer.

*220375==19999*

DR 0375 (10/19/22)
COLORADO DEPARTMENT OF REVENUE
Tax.Colorado.gov
Page 1 of 1

2022 Credit for Employer Paid Leave of Absence for Live Organ Donation
If claiming this credit and filing by paper, you must submit this schedule with your return.

                I am claiming a credit for 35% of my incurred expenses paid during my employee’s leave of absence period 
                for the purpose of live organ donation, or I am carrying forward unused credit from a prior tax year.
I attest to the following:

                I incurred the expenses (reported below) by paying my employee(s) wages (and for the cost of any 
                temporary replacement help) during my employee’s qualifying leave of absence period.

                I do not pay my employee(s) who had a qualifying leave of absence period $80,000 or more per 
                year in wages.

                I have and will maintain documentation that I received from my employee(s) from their medical provider 
                that verifies my employee’s live organ donation.
                                             Taxpayer Information
Last Name (or Business Name)                 First Name                                             SSN or FEIN
                                                                          
                                             Employee(s) Expense Information
1.  Sum the expenses (wages paid during the leave of absence period and costs of any temporary 
replacement help) you incurred during the tax year.                                                                      00

2.  Multiply line 1 by 0.35, this is the amount of current year credit available.                                        00
3.  Enter the amount of any credit for employer paid leave of absence for live organ donation that 
is carried forward from a prior year.                                                                                    00
4.  Enter the sum of lines 2 and 3. Transfer this sum to the appropriate form and line number 
indicated in the table below.                                                                                            00
By claiming this credit, I declare that to the best of my knowledge and belief, this affidavit is true, correct, and complete.

Form              Form Title                 Line               Form              Form Title                         Line
                                                                                  Colorado Pass-Through Entity 
DR 0104CR         Individual Credit Schedule 46A                DR 106CR                                               26A
                                                                                  Credit Schedule 

DR 0105           Schedule G (DR 0105)       10A                DR 0112CR         Credit Schedule for Corporations     26A