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(11/16/17)
          Booklet Includes:
                     DR 0021
                     DR 0021D
                                                                   Book
                     DR 0021S
                                                   21

                              Colorado Severance Tax Booklet

          Colorado Severance Tax Forms

          This book includes: DR 0021 
                              Oil and Gas  
                              Severance Tax Return

                              DR 0021D 
                              Oil and Gas Severance Tax 
                              Computation Schedule

                              DR 0021S 
                              Application for Extension of Time to 
                              File Colorado Severance Tax Return

          MAIL COLORADO SEVERANCE TAX RETURNS AND TAX 
          PAYMENTS TO

                     COLORADO DEPARTMENT OF REVENUE
                     Denver, CO 80261-0006

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against severance tax of 87.5% of your share of ad valorem
General Information taxes paid or assessed on actual oil or gas production (not
Colorado severance tax is imposed upon nonrenewable the tax on facilities or equipment). However, ad valorem
natural resources that are removed from the earth in taxes on production from “stripper wells” should not
Colorado. The tax is calculated on the gross income from be included in the credit. Specific instructions for this
oil and gas and carbon dioxide production. deduction are on the DR 0021D, Colorado Oil and Gas
Who Must File Return DR 0021 and Carbon Dioxide Severance Tax Schedule. You should
Anyone who receives taxable income from oil or gas verify that the withholding statements accurately report
produced in Colorado. If you are a producer or own a the same information as shown on your division of interest
working interest, or a royalty interest in any oil or gas statements and revenue checks.
(including carbon dioxide) produced in Colorado, or if
Important - Partners of a General Partnership
you receive royalties on Colorado oil shale, you must pay Partners of a General Partnership should attach a copy
severance tax to the State of Colorado. Severance tax of the partnership’s DR 0021W and a schedule detailing
might be due even though you do not realize a net profit on their individual portion of gross income and taxes paid or
your investment. withheld as reported on their individual returns.
A limited partnership, LLC or S Corporation must file at
the entity level. Partners, members, or shareholders do not file Filing Period
a severance tax return to report oil and gas income received by The Colorado severance tax filing period should match the
the pass-through entity. A General Partnership will not file at tax year/filing period used for federal income tax purposes.
the entity level. Each partner, and not the general partnership, Filing Status
is required to file a return. The Colorado filing status will generally match the filing
Oil and gas production from “stripper wells” is exempt status from your federal income tax return. However, the
from severance tax. This includes oil from a well that Colorado severance tax filing status will always be joint
produces 15 barrels or less of crude oil per day or gas if you are married - regardless of whether you file jointly
from a well that produces 90,000 cubic feet or less of gas or separately. Single or head of household filing statuses
per day, for the average of all producing days during the should file a single status Colorado severance tax return.
taxable year.
Due Date
You must complete and file the DR 0021, Colorado Oil
Exception and Gas Severance Tax Return annually. The return (and
It is not necessary to file a severance tax return if payment, if any) are due by the 15th day of the fourth
you meet both of the following conditions: month after the close of your taxable year. Therefore, if
1. the total gross oil and gas withholding on form(s) your taxable year ends on December 31, your severance
DR 0021W for the calendar year is less than $250; tax return is due April 15 of the following year. The
and envelope must be postmarked by the due date, or the next
business day if the deadline falls on a Saturday, Sunday or
2. the producer has withheld sufficiently from
holiday.
royalty or production payments to cover the
severance tax liability. Mail Colorado severance tax returns and tax payments to:
Colorado Department of Revenue
Severance Withholding Denver, CO 80261-0006
Producers or first purchasers who disburse funds must
Filing Extension
withhold 1% of the gross income for each interest owner.
If you are unable to complete your severance tax return by
This can include royalty, working interest or any other
the due date and you estimate that you will owe severance
interest owner.
tax, you can request a six-month extension by filing the
The producer or first purchaser is required to send the DR 0021S on page 11. If no balance of severance tax is
DR 0021W, Oil and Gas Withholding Statement to interest due, an extension for filing is not required.
owners by March 1 of each year. This form lists the gross
The DR 0021S is an extension of time to file your return. It
income and the amount of severance tax the producer
is not an extension of time to pay severance tax.
has withheld and paid to the state from your royalty or
production payments. If you own an interest in more than A filing extension granted by the federal government will
one well or field, you should receive a separate withholding not be honored for the Colorado severance tax return.
statement from each producer or first purchaser. A copy Also, any extension to file Colorado income tax returns
of each withholding statement must be attached to your does not apply to the Colorado severance tax return.
severance tax return (DR 0021). Amended Returns
The producer or first purchaser will also list your share of To change or correct a Colorado severance tax return, you
“ad valorem” taxes, if any, on the withholding statement. must file a DR 0021X. This form is available for download
Ad valorem taxes are paid by the producer to local from Colorado.gov/Tax – the official Taxation web site.
governments (cities and counties). You are allowed a credit

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Returns For Prior Years                                          Common Filing Errors 
Colorado severance tax returns for prior years can be filed      Be alert to the following filing tips to avoid delays in return 
at any time. However, the statute of limitations for claiming a  processing, payments and refunds.
severance tax refund is three years from the due date.
                                                                 • Indicate the correct tax or fiscal year when filing a 
Estimated Severance Tax Payments                                   Colorado severance tax return.
Corporations who expect their Colorado severance tax 
liability for the year to exceed their Colorado severance        • Married couples must file jointly even if only one 
credits by $5,000 or more are required to make estimated           spouse has oil and gas income.
tax payments. Estimated tax payments are due each                • Taxpayers must complete the DR 0021D, Colorado Oil 
month by the 15th day of that month and must be submitted          and Gas Severance Tax Schedule, and attach it to the 
by Electronic Funds Transfer (EFT). A paper form for these         DR 0021 return. Both of these forms are in this booklet.
tax payments is not required; the EFT transaction is the filing. 
Visit Colorado.gov/Revenue/EFT for more information on           • Be sure to carry the correct totals from the DR 0021D 
how to register and file through EFT.                              schedule to the DR 0021 return.
Individuals are not required to make estimated payments          • Attach all DR 0021Ws (Oil and Gas Withholding 
for severance tax.                                                 Statement) to the DR 0021 return. Missing DR 0021Ws 
                                                                   result in delayed refunds.
Deceased Persons
Legal representatives and surviving spouses may file a           • Add up all the DR 0021W withholding statements, 
return on behalf of a deceased person. Complete the return         then round to the nearest dollar. Do not round each 
as usual. Write “Deceased” in large letters in the white           individual DR 0021W statement and then add them.
space above the tax year of the return, mark the deceased 
box for the appropriate person, and fill in the date of          • Do not use a 1099-MISC withholding document for 
death. Write “Filing as surviving spouse” or “Filing as legal      severance tax filing. 1099s are income tax withholding 
representative” after your signature, and attach the DR 0102       documents. They will not report severance tax 
(refunds only) and a copy of the death certificate.                withholding and the department will not allow credit 
                                                                   based on the withholding shown on a 1099 document.
Record Retention
Keep all documentation you used to prepare your return           • Do not try to claim a percentage of the withholding 
for at least three years after the due date or filing date of      shown on the DR 0021W and do not create 
your return, whichever is later. If your return is audited by      spreadsheets to show the ownership percentage. 
the Colorado Department of Revenue, you must be able to            Use the amounts on the DR 0021W. The ownership 
provide back-up documents for all claims and credits listed on     percentage has already been calculated by the entity 
your return. Please note that you are not protected from audit     that issued the DR 0021W withholding statement.
adjustments to your severance tax return simply because            Do not claim all of the withholding but only part of the 
                                                                 • 
an operator or purchaser supplied the information. Also, the 
                                                                   income.
Department of Revenue may request copies of your federal 
and Colorado income tax return or other documentation in         • Do not deduct gross payments attributable to stripper 
connection with your Colorado severance return.                    well production if these are not shown as stripper well 
                                                                   income on a DR 0021W.
Income Tax Filing Requirement 
Severance tax is different from income tax. If you receive       • Taxpayers are either on an accrual basis or a cash 
oil, gas or CO 2income from Colorado sources you must              basis — not both. Most individuals are on a cash basis 
also complete and file a Colorado state income tax return.         while most corporations are on an accrual basis.
Visit Colorado.gov/Tax to download the DR 0104, which 
can be filed electronically for free using Revenue Online.       • If a return is filed on behalf of an entity such as 
                                                                   partnership or limited liability company, do not try to file 
See the DR 0104 for details. Do not claim severance tax 
                                                                   as an individual.
withholding as a tax credit on your Colorado income 
tax return.                                                      • Corporations that expect their Colorado severance 
Failure To File                                                    tax liability for a tax year to exceed their Colorado 
If your severance tax account is open, or if you have              severance tax credits by $5,000 or more are required 
severance income that is reported to the Colorado                  to make estimated tax payments.
Department of Revenue and you do not file a return for the       • To avoid underestimation penalties, corporations must 
tax period, the Department may file a return on your behalf.       make severance tax estimated payments by the 15th 
See Exception on page 2. Any severance tax assessed will           day of the month and payments must be submitted by 
remain due and payable until you file your return or close         EFT.
your account. If you are no longer doing business in the 
State of Colorado, you are required to close your account        Please visit Colorado.gov/Tax for more information.
by filing the DR 1102, Account Change or Closure Form.

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DR 0021 Instructions                                            Line 4 Severance Tax Withheld
                                                                Enter the total amount shown on all of your oil and 
Who Must File                                                   gas withholding statements (DR 0021W) as Colorado 
Every individual, corporation, business trust, limited          severance tax withheld. Add all amounts, then round to the 
partnership, LLC, partner in a general partnership,             nearest dollar. Be sure to attach your DR 0021W forms 
association, estate, trust or any other legal entity that       to your return; missing DR 0021Ws will delay your refund. 
received income from oil and gas produced in Colorado           Do not claim credit for conservation tax or ad valorem 
must file a severance tax return. The return must be            taxes on this line.
made for the same tax year used for federal income tax 
                                                                Line 5 Estimated Tax and Extension Payments
purposes and is due on or before the 15th day of the fourth     Enter on the total amount of your estimated tax and 
month following the end of the taxable year. See General        extension payments made for the taxable year.
Information section for exception. If you are an oil and gas 
producer you must complete the DR 0021PD and retain for         Refund or Balance Due
your records.
                                                                Line 7 Overpayment
Controlled group: corporations, family group,                   Subtract line 3 from line 6 and enter the difference on line 
or other type of group                                          7. The Department will send you a refund check for this 
In the case of a controlled group of corporations as defined    amount if your return is properly completed.
in section 613A of the Internal Revenue Code where more         Line 8 Refund
than one member of the group is subject to the severance        Enter the amount from line 7 that you wish to have 
tax, the tax must be jointly computed and the severance         refunded. The Department can deposit your refund 
tax return must be jointly filed under the name of the          directly in to your account at a U.S. bank or other financial 
principal taxpaying corporation. DR 0021AS, available at        institution (such as a mutual fund, brokerage firm, or credit 
Colorado.gov/Tax must be attached.                              union) in the United States.
Joint Returns                                                   Line 9 Refund Applied to Future Period
When more than one member of a family is subject to the         Enter on line 9 the amount of overpayment, if any, you wish 
severance tax, they shall compute the severance tax on one      credited to estimated severance tax payment for next year.
combined return. Note: parties to a Civil Union should refer to 
federal tax law to determine the correct filing status.         Line 10 Tax You Owe
                                                                If line 3 is more than line 6, you have additional tax to pay. 
Social Security or Colorado Account Number                      Subtract line 6 from line 3 and enter the difference on 
Individuals must use a Social Security number as the            line 10. This is the amount you owe. Attach to your return 
Colorado account number. Business entities must provide         a check or money order in this amount payable to the 
the Colorado account number (CAN) and the Federal               Colorado Department of Revenue. Be sure to write your 
Employer Identification Number (FEIN). Whether you are an       Social Security number or Colorado account number 
individual or a business entity, once you have been assigned    on your check or money order to ensure credit for 
a Colorado account number by the Colorado Department of 
                                                                your payment.
Revenue, use the Colorado account number on all returns 
and correspondence submitted to the Department. See             Line 11 Interest
Colorado.gov/Tax for Privacy Act Notice.                        If the return is filed after the due date, interest at the 
                                                                current statutory rate will accrue on any balance of tax due 
Tax and Credit                                                  until paid. The interest rate is 6% per year if we bill you and 
First, complete schedule DR 0021D to calculate your             your payment is made more than 30 days after you receive 
severance tax.                                                  your bill. If you pay your tax with your return or within 30 
                                                                days of receiving a bill, the interest rate is 3% per year. 
Line 1 Oil and Gas Severance Tax                                Enter the amount of late filing interest on line 11.
Enter your net tax from line 5 of schedule DR 0021D.
                                                                Line 12 Penalty
Line 2 Impact Assistance Credit                                 The penalty on any late filed return with a balance of tax 
A credit against the severance tax is allowed with respect 
                                                                due is $30 or 30% of the balance of tax due, whichever is 
to contributions to local government that are deemed to be 
                                                                greater. Enter the amount of late filing penalty on line 12.
necessary because of a new severance operation or the 
increase in production at an existing operation. The amount     Line 13 Estimated Tax Penalty
of the credit must be certified by the Executive Director       Corporations that underpay the estimated tax must enter 
of the Department of Local Affairs. Enter your impact           the penalty due from the DR 0206.
assistance credit for the year on line 2.
Line 3 Net Tax                                                  Be sure to sign your return! If filing a joint return, both 
Subtract line 2 from line 1, and enter the difference on line   parties must sign. 
3. If line 2 is larger than line 1, enter zero.                 To ensure proper processing, please include your 
                                                                account number on the return.

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           Departmental Use Only
                                               DR 0021 (07/21/17) 
                                               COLORADO DEPARTMENT OF REVENUE 
                                               Denver, CO  80261-0006 
                                               Colorado.gov/Tax
                                               (7001)

                                                                                         Colorado
                                                          Severance Tax–Oil and Gas DR 0021
*150021==19999*
Fiscal Year Beginning (MM/DD/YY)                                        Ending (MM/DD/YY)

Last Name or Business Name                                                               First Name       Middle Initial

                                 Date Deceased (MM/DD/YY)      SSN                                  Colorado Account Number
  Deceased            Yes

If Joint, Spouse or Partner Last Name (see controlled group definition)                  First Name       Middle Initial

                                 Date Deceased (MM/DD/YY)                                SSN
  Deceased            Yes

Address                                                                                             FEIN

Foreign Country                                           City                           State ZIP  Phone Number

If this is a final return check this box       Are you a producer of Colorado Oil or Gas?             Yes   No

Tax and Credit – Complete schedule DR 0021D first. Attach the DR 0021D to this                      Round To The 
                 form when you file                                                                 Nearest Dollar

1. Oil and gas tax, enter amount from line 5, DR 0021D                                            1               00
                                                                                               •
2. Impact assistance credit                                                                       2               00
                                                                                               •
3. Net tax, line 1 minus line 2 but not less than zero                                           3                00
                                                          Prepayments

4. Severance tax withheld, attach form DR 0021W                                                  4                00
                                                                                               • 
5. Estimated tax and extension payments                                                           5               00
                                                                                               •
6. Total prepayments, add lines 4 and 5                                                          6                00
                                                               Refund

7. If line 6 is larger than line 3, enter your overpayment                                       7                00

8. Enter amount from line 7 you want refunded                                                    8                00
                                                                                               • 
9. Enter amount from line 7, if any, you want credited to estimated tax for next year             9               00
                                                                                               •

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                                                DR 0021 
                                                (07/21/17)            Colorado
*150021==29999*                                 Severance Tax–Oil and Gas DR 0021
 Name                                                                                 Account Number

                                 Routing Number                            Type:   Checking       Savings
        Direct
        Deposit                  Account Number

                                                   Balance Due

 10. If line 3 is larger than line 6, enter the balance due here                  10                               00

 11. Interest on balance due                                                       11                              00
                                                                                 •
 12. Penalty on balance due                                                        12                              00
                                                                                 •
 13. Estimated tax penalty (corporations only)                                     13                              00
                                                                                 •

 14. Total amount due, add lines 10, 11, 12 and 13                 Paid by EFT    14
                                                                                 •                                 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.
                       Mail Your Severance Tax Return Separately From Your Income Tax Return.
                                 Attach Form DR 0021W Withholding Forms.
Mail to and make checks payable to:  Colorado Department of Revenue
                                                Denver, CO 80261-0006
Under penalty of perjury in the second degree, I declare that I have examined this return and to the best of my 
knowledge and belief it is true, correct, and complete.
Signature of Individual Taxpayer                                                             Date (MM/DD/YY)

Spouse’s Signature                                                                           Date (MM/DD/YY)

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

Preparer’s Last Name                            Preparer’s First Name                        Preparer’s Phone Number

Address                                                                    City             State Zip

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same way on the severance tax schedule (DR 0021D).
Instructions For Preparing You should include only the income received in the tax
Severance Tax Schedule DR 0021D period. If you use the accrual basis (this applies to most
Use the DR 0021D to calculate the amount of Colorado corporations), you must report income from all production
severance tax to enter on line 1 of the DR 0021. in the tax period whether you actually received the
income or not, including deferred amounts if they are
Based on your accounting method (cash or accrual reported on the federal income tax return.
basis), use the amounts listed on the DR 0021W you
received to complete DR 0021D. If you disagree with the Cash-Basis Taxpayers
information provided by a producer/first purchaser, Report only ad valorem tax (on production) actually paid
you must request a corrected DR 0021W prior to to the county assessor during the severance tax year.
completing the DR 0021D. Round all amounts to whole Payments to operators of wells do not qualify, only actual
dollars. payments to the assessor. If a payment is skipped during
a tax year, (for example, delinquent) no claim for tax is
Column allowed. Catch-up or double payments must all be claimed
(A) Producer Name. Enter in column (A) the name of in the year paid and cannot be carried back or forward.
the producer/first purchaser from each DR 0021W. All
information entered on form DR 0021D must have a Accrual Basis Taxpayers
form DR 0021W included with the return. Report only ad valorem tax (on production) levied, or
assessed, within the severance tax year. In November
(B) Gross Income. Enter in column (B) the gross income or December, depending upon the year, the Colorado
as reported on DR 0021W. This is your share of counties set the mill levy for assessment of ad valorem tax
the gross income received or accrued on oil or gas on the prior year’s oil and gas production. The ad valorem
production. tax is not accruable until the amount is established on
(C) Gross Income Attributable To Stripper Well that date.
Production. Enter in column (C) the gross income
Short Period Returns
attributable to stripper well production as reported on Because severance tax requires filing periods consistent
the DR 0021W. with federal income tax filing years, some companies may
(D) Net Gross Income. Enter in column (D) the net have to file short period severance tax returns to match
gross income by subtracting the stripper well gross their federal filings. The same ad valorem rules apply. If no
income listed in column (C) from the gross income payment (cash -basis) or accrual date (accrual basis) falls
listed in column (B). within the short tax period, no claim for ad valorem tax is
(E) Ad Valorem Tax. Enter in column (E) the ad valorem allowed. (Also, if the levy or payment date does fall in the
tax as reported on the DR 0021W. This is the amount short period, all the tax applies to only that short period.)
paid or accrued to Colorado local governments in
the taxable year on oil and gas production. Do not To expedite the processing of your severance tax
include ad valorem tax on buildings, improvements, return, attach all documentation to support ad valorem
or equipment. A percentage of ad valorem tax is taxes, gross income and severance tax withheld.
allowed as a reduction to the severance tax. Mail your severance tax return and payment, if any,
separately from your Colorado income tax return or any
(F) Ad Valorem Tax Attributable To Stripper Well
other tax return.
Production. Enter in column (F) the ad valorem tax
attributable to stripper well production as reported on
the DR 0021W.
(G) Net Ad Valorem Tax. Enter in column (G) the net
ad valorem tax by subtracting the stripper well ad
valorem tax listed in column (F) from the ad valorem
tax listed in column (E).

**Note** Reporting revenue and ad valorem taxes in the
correct tax year is critical to filing a correct return. Please
review the following information.

Cash or Accrual Basis. Oil and gas revenue and related
ad valorem tax must be reported on a basis consistent
with the basis used for filing your federal income tax
return. Thus, if you are a cash-basis federal taxpayer
(this applies to most individuals), reporting income when
received and deductions when paid, you must report the

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                                                      DR 0021D (07/21/17) 
                                                      COLORADO DEPARTMENT OF REVENUE 
                                                      Denver, CO 80261-0006 
*150021D=19999*                                       Colorado.gov/Tax

                                                        Colorado Oil And Gas Severance Tax 
                                                             Schedule (Attach to the DR 0021)
For tax year beginning (MM/YY)     Ending (MM/YY)            Page           Of
                                                                                        Please round to whole dollars.

Taxpayer’s Last Name                              First Name                        Middle Initial SSN or Colorado Account Number

   (A)                         (B)                (C)             (D)               (E)            (F)          (G)
Producer Name  Gross Income Gross Income                     Net Gross              Ad Valorem     Ad Valorem   Net Ad 
List each 0021W                           Attributable       Income                             Attributable to Valorem
   on a                                   to Stripper Well (Column B-C)                            Stripper Well   (Column E-F)
Separate Line                             Production                                               Production

Check Accounting Method              cash-basis       or            accrual basis

1. Net gross income [total of column (D)]                                                       1                      00
                                                                                        • 
2. Tax on total net gross income (see tax rate schedule below)                                  2                      00
                                                                                        •
3. Net ad valorem tax [total of column (G)]                                                     3                      00
                                                                                        •
4. Ad valorem tax credit, 87.5% of the amount on line 3                                         4                      00
                                                                                        •
5. Net tax on oil and gas income, line 2 minus line 4. If line 4 is larger enter 0. 
   Enter here and on line 1 of the DR 0021.                                                     5                      00
                                                      Tax Rate Schedule
If total net gross income is:                         The tax is:
Under $25,000                                         2% of gross income
$25,000–$99,999                                       $500 plus 3% of the excess over $24,999
$100,000–$299,999                                     $2,750 plus 4% of the excess over $99,999
$300,000 and over                                     $10,750 plus 5% of the excess over $299,999

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                                                 DR 0021S (07/21/17) 
                                                 COLORADO DEPARTMENT OF REVENUE                                 (7040)
                                                 Denver, CO 80261-0008 
*150021S=19999*                                  Colorado.gov/Tax

                        Extension Of Time For Filing Colorado  
                        Oil And Gas Severance Tax Return

Colorado severance tax returns are due to be filed by the        If after the original due date of the return it is found that the 
fifteenth day of the fourth month after the close of the tax     amount paid is insufficient to meet the 90% requirement, 
year.                                                            additional payment should be made as soon as possible 
An automatic six-month extension of time for filing the          to reduce accumulation of penalty and interest. Make such 
Colorado severance tax return is allowed for all taxpayers.      payment with the DR 0021S.
However, an extension of time to file is not an extension        Be sure to round your payment to the nearest dollar. The 
of time to pay the tax. If at least 90% of the net tax liability amount on the check and the amount entered on the 
is not paid by the original due date of the return, penalty      payment form must be the same. This will help maintain 
and interest will be assessed. If 90% or more of the net tax     accuracy in your tax account.
liability is paid by the original due date of the return and the Submit the DR 0021S with payment to:
balance is paid when the return is filed by the last day of the 
                                                                                Colorado Department of Revenue 
extension period, only interest will be assessed.
                                                                                Denver, CO 80261-0008
Use the DR 0021S to make a payment that must be made 
by the original due date of the return to meet the 90% 
requirement.
                                                        Worksheet
 1.   Tentative amount of tax for the taxable year after reduction for the impact 
      assistance credit (if any)                                                                                                            $

 2.   Less: (a) Severance tax withheld                                                                                                      $

                (b) Estimated tax payments                                                                                                  $

                (c) Total (a) and (b)                                                                                                       $
 3.   Balance to be remitted with this request for extension, line 1 minus line 2 (c). 
      Enter amount of payment below. Claim credit for this payment on line 5 of the DR 0021                                                 $
                                      If no payment is due, do not file the DR 0021S.
DR 0021S (02/16/16)
Return the DR 0021S with check or money order payable to the Colorado Department of Revenue, Denver, Colorado 80261-
0008. Write your Social Security number, Colorado Account Number or Federal Employer Identification Number and DR 
0021S on your check or money order. Do not send cash. Enclose, but do not staple or attach, your payment with this form.
For tax period: (MM/YY)                                          Ending: (MM/YY)

Your Last Name                                          First Name                                              Middle Initial              SSN

Spouse’s Last Name                                      First Name                                              Middle Initial              Spouse’s SSN

Address                                                                                                                                     FEIN

City                                             State      ZIP          Foreign Country

If no payment is due, do not file this form.                                                                                                    Amount Owed
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.                             $              .00

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COLORADO DEPARTMENT OF REVENUE
Denver, CO  80261-0006 
Colorado.gov/Tax

                                           Secure Messaging
Contact Department of Revenue support staff electronically through Revenue Online. This service is secure and 
                       confidential. Visit Colorado.gov/RevenueOnline to register and get started.

                                           Call Center
                                           Assistance 303-238-SERV (7378) 
                                           Monday–Friday 8:00 a.m.–4:30 p.m.

                                           Service Centers
                       Forms and information are available Monday through Friday, 8 a.m. to 4:30 p.m. 
                       You may find directions to each service center on our web site at Colorado.gov/Tax

Colorado Springs                                                                         Grand Junction 
2447 N. Union Blvd.                        Denver                                        222 S. 6th Street, Room 208
                                           1375 Sherman Street
                Pueblo                                                                   Fort Collins 
827 W. 4th Street, Suite A                                                               3030 S. College Avenue

                       Visit Colorado.gov/Tax to find other severance tax 
                              forms and schedules not included in this booklet.

PDF file checksum: 3223844114

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