DR 0456 (07/13/22)
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261-0006
Tax.Colorado.gov

Colorado Annual Reconciliation Of Oil and Gas Severance Withholding

                                       Instructions and Information
                                                 (See form on page 2)
This reconciliation must be filed with the Colorado          The DR 0021W forms can be submitted electronically via 
Department of Revenue on or before April 15, following       Revenue Online at www.Colorado.gov/RevenueOnline   
the close of the calendar year. Copies of each DR 0021W,     Please review FYI publication - Withholding 9 for filing 
Oil and Gas Withholding Statement, that was issued by        specifications. This form DR 0456 should be submitted to 
this entity must also accompany this form. Unless the        the address shown below.
production is exempt from tax, a DR 0021W must be            COLORADO DEPARTMENT OF REVENUE
issued to any person or entity with a working interest,      Denver, CO 80261-0006
royalty interest, production payment, or any other interest 
in the oil or gas that was produced in Colorado.             This address and ZIP code is exclusive to the Colorado 
                                                             Department of Revenue, so a street address is not 
Failure to file this Annual Reconciliation and/or the        required.
accompanying DR 0021W forms can result in a penalty of 
15% or $1,500, whichever is less.

Reminders                                                    Line 16
Please be sure to submit copies of all DR 0021W forms        Line 13 minus line 14; this will be any refund due.
with the DR 0456 return.
                                                             Line 17
If you filed 12 consecutive months of zero returns, you      Failure to file a return and pay the tax on or before the 
should close your account.                                   due date will result in a penalty at the rate of 30% or $30, 
Be sure to round all amounts to the nearest dollar. Make     whichever is greater, per §39-29-115(1), C.R.S.
sure the amount of your payment matches the amount           Line 18
listed on line 19 on the form.                               Failure to file a return and pay the tax on or before the due 
                                                             date will result in interest at the current statutory rate from 
Lines 1–12
The total oil and gas severance taxes withheld per the       the due date of payment. See FYI publication - General 11 
DR 0021W(s).                                                 for more information.
Line 13                                                      Line 19
Total severance taxes withheld and remitted to the           Total amount owed with this report. You must round to the 
Colorado Department of Revenue during the calendar year.     nearest dollar.
                                                             Please see FYI publication - Withholding 4, Colorado Oil 
Line 14
The total on line 14 should match the amount of Colorado     and Gas Severance Withholding Requirements. For further 
severance tax withheld from all DR 0021W forms issued.       information call (303) 238-SERV (7378) or visit the Official 
                                                             Taxation Web site, Tax.Colorado.gov
Line 15
Line 14 minus line 13; this will be the additional severance 
withholding tax due.

                                                      DR 0456 (07/13/22)
                                                      COLORADO DEPARTMENT OF REVENUE
                                                      Denver CO 80261-0006
*210456==19999*                                       Tax.Colorado.gov
                                                      Page 1 of 1
                                                      (7023)

                                                          Colorado Annual Reconciliation Of Oil 
                                                                  and Gas Severance Withholding
                                                                                      List the total monthly oil and gas 
                                                                                      severance tax withheld

                                                                                      1.  January      1                                                                                     00

                                                                                      2.  February     2                                                                                     00

                                                                                      3.  March        3                                                                                     00
Mail to and Make Checks Payable to: Colorado Department of Revenue
                                           Denver Colorado 80261-0006                 4.  April        4                                                                                     00
Instructions: The DR 0456 must be filed with the Colorado Department 
                                                                                      5.  May          5                                                                                     00
of Revenue on or before April 15, following the close of the calendar year. 
The Oil and Gas Withholding Statement (DR 0021W) must be submitted for 
                                                                                      6.  June         6                                                                                     00
each person who had Colorado gross severance tax withheld from oil and 
gas payments during the calendar year.
                                                                                      7.  July         7                                                                                     00
Last Name or Business Name                 First Name                   Middle Initial
                                                                                      8.  August       8                                                                                     00
Address
                                                                                      9.  September    9                                                                                     00
City                                                      State  ZIP
                                                                                      10. October      10                                                                                    00
FEIN                                       Colorado Account Number
                                                                                      11. November     11                                                                                    00
Period Ending (YYYY)                       Due Date (YYYY)
  Dec. 31 20                                 April 15 20                              12. December     12                                                                                    00

13.  Total Colorado severance taxes remitted to the Department of Revenue during the year              13                                                                                    00
14.  Sum of Colorado severance tax withheld from all             Quantity of DR 0021W forms prepared
     DR 0021W forms issued                                                                             14                                                                                    00

15.  Additional severance withholding tax due (line 14 minus line 13)                                  15                                                                                    00

16.  Refund (line 13 minus line 14)                                                                     16                                                                                   00

17.  Penalty (see instructions)                                                                         17                                                                                   00

18.  Interest        % per month                                                                        18                                                                                   00

19.  Total Amount Owed with this report                                                Paid by EFT 
                                                                                                       19  $             .00
The State may convert your check to a one time electronic banking transaction. Your bank account may be debited as early as the same day received by the State. If converted, your check will 
not be returned. If your check is rejected due to insufficient or uncollected funds, the Department of Revenue may collect the payment amount directly from your bank account electronically.
I certify that under penalty of perjury in the second degree that to the best of my knowledge the above information is true and correct.
Name of Business or Taxpayer                                                                           Date (MM/DD/YY)

Signature of Taxpayer or Corporate Officer                                                             Date (MM/DD/YY)

                                Submit copies of all DR 0021W forms with this return