DR 1210 (10/03)
COLORADO DEPARTMENT OF REVENUE       COLORADO ESTATE TAX RETURN
1375 SHERMAN STREET                           DUE DATE:  ON OR BEFORE THE DATE THE
DENVER CO 80261
www.taxcolorado.com                  FEDERAL RETURN IS REQUIRED TO BE FILED.

 TO BE FILED ONLY IF DATE OF DEATH IS ON OR AFTER JANUARY 1, 1980.  CHECK THE
APPLICABLE STATEMENT LISTED BELOW:
     A Federal return is not required to be filed but a Certificate of Estate Tax Determination
     is requested. Complete Sections I and II below.

     A Federal return is attached but no Colorado estate tax is due. A Certificate of
     Estate Tax Determination  is requested.  Complete Sections I and II below.

     A Federal return is attached and a Colorado estate tax is due. A Certificate of Estate
     Tax Determination is requested.
                                                                                                Department of Revenue Use Only
FOR DEPARTMENT USE ONLY

ACCOUNT NUMBER: L2126495                        PERIOD _____________________                            LIABILITY: 2800-800

     Attached is a payment for Colorado tax in amount         (999) $
     The amount of payment was computed in accordance with Schedule A, B, C and                 Decedent was:
     Recapitulation page 2.                                                                             Domiciliary
                                                                                                        Non-Domiciliary
                                                                                                        of Colorado.
                                                                                                        Alien
An extension of time to file the Federal return         has   has not been approved.
                                                                                                        The Estate has elected
A true copy of such approved extension is attached.  Extension date: ________________________           10 yr           15 yr
                                                                                                        installment payments.
An extension of time to pay  the Federal tax            has   has not been approved.
                                                                                                        First payment due date:
A true copy of such approved extension is attached.  Extension date: _______________________
                                                                                                        ____________________
SECTION I
Estate of                                                            Date of Death              Decedent's Social Security Number

Domicile at Date of Death (Number and Street)           City               County               State              Zip

Name of Personal Representative or person filing return              Address (Number and Street)

City                                                    State        Zip             Telephone

Name of Attorney                                                     Address (Number and Street)

City                                                    State        Zip             Telephone:

SECTION II
Enter the total gross value of the decedent's estate. Gross value means the total value of assets before any deductions.
Colorado Assets

Non-Colorado Assets

TOTAL

I declare, under penalties of perjury in the second degree, that I have examined this return including any and all accompanying
schedules or attachments and that I believe the same to be true and correct as to every material matter.
Signature of person filing return                                    Title                                         Date

Signature of person preparing return                                 Title                                         Date

SCHEDULE A - Computation of Tax - Domiciliary Decedent's Estate - Federal Estate Tax
1.  Total State death tax credit allowable for Federal estate tax purposes             . . . . . . . . . . . . . . . . . . . . . . . . . . .         $

2.  Taxes paid to other states qualifying for Federal estate tax  State death tax credit.
    (Attach copy of return.  Provide evidence of payment as soon as possible.)         . . . . . . . $

3.  Proration of Federal estate tax State death tax credit:
    a. Gross value for Federal estate tax purposes of property in states other
       than Colorado (identify on attached Federal tax return)                         . . . . . . . . . . . . . . . . . . . $
    b. Gross value of decedent's estate for Federal estate tax purposes                . . . . . . . . . . .                 $
    c. Percent of estate for Federal estate tax purposes located in states other
       than Colorado (line 3a divided by line 3b.) . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                      %
    d. Amount of credit attributable to property located in states other than
       Colorado (line 1 multiplied by line 3c.) . . . . . . . . . . . . . . . . . . . . . . . . . . . .                      $

4.  Deduction for taxes paid to other states (line 2 or line 3d, whichever is smaller) . . . . . . . . . . . . . . . . . . .                         $
                                                                                                                                                     $
5.  Tax payable to Colorado (line 1 less line 4).  Enter on line 11, below.            . . . . . . . . . . . . . . . . . . . . . . . . . .
SCHEDULE B - Computation of Tax - Non-Domiciliary or Alien Decedent's Estate - Federal Estate Tax
1.  Total State death tax credit allowable for Federal estate tax purposes . . . . . . . . . . . . . . . . . . . . . . . . . . .                     $

2.  Gross value for Federal estate tax purposes of property located in Colorado
    (identify on attached Federal estate tax return) . . . . . . . . . . . . . . . . . . . . . . . . . . .                   $

3.  Gross value of decedent's estate for Federal estate tax purposes . . . . . . . . . . . . . . . . $

4.  Percent of Federal estate located in Colorado (line 2 divided by line 3)           . . . . . . . . . .                                      %

5.  Tax payable to Colorado (line 1 multiplied by line 4). Enter on line 11, below.. . . . . . . . . . . . . . . . . . . . .  .                      $

SCHEDULE C - Computation of Tax - Generation Skipping Transfer Tax
6.  Total State death tax credit allowable for Federal generation skipping transfer tax  purposes . . . . . . . . . . . .                            $

7.  Gross value for Federal generation skipping transfer tax purposes of property located in
    Colorado (identify on attached Federal generation skipping  transfer tax return)   . . . . .                             $

8.  Gross value of estate for Federal generation skipping transfer tax purposes . . . . . . . .                              $

9.  Percent of property subject to Federal generation skipping transfer tax located in
    Colorado (line 7 divided by line 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                   %

10. Tax payable to Colorado (line 6 multiplied by line 9). Enter on line 11, below.    . . . . . . . . . . . . . . . . . . . . . .                   $
RECAPITULATION                                                                                                                                  (05)
                                                                                                                                                     $
11. Amount of tax payable to Colorado (Schedule A line 5 or Schedule B line 5, plus line 10) . . . . . . . . . . . .
12. Penalties:
    Date of death prior to January 1, 1986:
       Late filing penalty (5%  for each month or portion thereof - maximum penalty 25%)                                                        (01) $
                                                                                                                             . . . . . . . . . .
    Date of death on or after January 1, 1986:
                                                                                                                                                (01) $
       Late filing penalty (5% for each month or portion thereof - maximum penalty 20%)                                      . . . . . .  . . .
       Late payment penalty (the greater of $15.00 or 5% for each month or portion       . . . . . . . . . . . . . .                            (09) $
       thereof  - maximum penalty 20%)
    NOTE:   If the late filing and late payment penalties both apply, only one of the two shall
    be assessed.
13. Interest at                           %  from                                   to   . . . . . . . . . . . . . . (03)                            $

14. Total tax, penalty, and interest payable (total of lines 11, 12, and 13)           . . . . . . . . . . . . . . . . . . . . . . . . . . . .       $

15. Prior payments (attach explanation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        $
                                                                                                                                                     $
16. Balance due (line 14 minus line 15) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . .