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(09/18/13)

                        2013

          Colorado Severance 

                                         Tax Booklet

                        THIS BOOKLET CONTAINS:

                                                                        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

                                                     Severance Tax Forms
          All forms in this booklet may be photocopied. Other severance tax forms and 
          schedules not included in this booklet can be accessed on the Web site at: 
                                                         www.TaxColorado.com



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                                                                 taxes paid or assessed on actual oil or gas production (not 
General Information                                              the tax on facilities or equipment). However, ad valorem 
Colorado severance tax is imposed upon nonrenewable              taxes on production from “stripper wells” should not 
natural resources that are removed from the earth in             be included in the credit. Specific instructions for this 
Colorado. The tax is calculated on the gross income from         deduction are on the DR 0021D, Colorado Oil and Gas 
oil and gas and carbon dioxide production.                       and Carbon Dioxide Severance Tax Schedule. You should 
Who Must File Return DR 0021                                     verify that the withholding statements accurately report 
Anyone who receives taxable income from oil or gas               the same information as shown on your division of interest 
produced in Colorado. If you are a producer or own a             statements and revenue checks.
working interest, or a royalty interest in any oil or gas 
                                                                 Important - Partners of a General Partnership
(including carbon dioxide) produced in Colorado, or if           Partners of a General Partnership should attach a copy 
you receive royalties on Colorado oil shale, you must pay        of the partnership’s DR 0021W and a schedule detailing 
severance tax to the State of Colorado. Severance tax            their individual portion of gross income and taxes paid 
might be due even though you do not realize a net profit on      or withheld as reported on their individual returns.
your investment.
A limited partnership, LLC or S Corporation must file at         Filing Period
the entity level. Partners, members, or shareholders do not file The Colorado severance tax filing period should match the 
a severance tax return to report oil and gas income received by  tax year/filing period used for federal income tax purposes.
the pass-through entity. A General Partnership will not file at  Filing Status
the entity level. Each partner, and not the general partnership, The Colorado filing status will generally match the filing 
is required to file a return.                                    status from your federal income tax return. However, the 
Oil and gas production from “stripper wells” is exempt           Colorado severance tax filing status will always be joint 
from severance tax. This includes oil from a well that           if you are married - regardless of whether you file jointly 
produces 15 barrels or less of crude oil per day or gas          or separately. Single or head of household filing statuses 
from a well that produces 90,000 cubic feet or less of gas       should file a single status Colorado severance tax return.
per day, for the average of all producing days during the 
                                                                 Due Date
taxable year.                                                    You must complete and file the DR 0021, Colorado Oil 
                                                                 and Gas Severance Tax Return annually. The return (and 
Exception                                                        payment, if any) are due by the 15th day of the fourth 
It is not necessary to file a severance tax return if you 
                                                                 month after the close of your taxable year. Therefore, if 
meet both of the following conditions:
                                                                 your taxable year ends on December 31, your severance 
1. the total gross oil and gas withholding on form(s)            tax return is due April 15 of the following year. The 
DR 21W for the calendar year is less than $250; and              envelope must be postmarked by the due date, or the next 
2. the producer has withheld sufficiently from royalty           business day if the deadline falls on a Saturday, Sunday or 
or production payments to cover the severance tax                holiday.
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 
withhold 1% of the gross income for each interest owner.         Filing Extension
This can include royalty, working interest or any other          If you are unable to complete your severance tax return by 
interest owner.                                                  the due date and you estimate that you will owe severance 
The producer or first purchaser is required to send the          tax, you can request a six-month extension by filing the 
DR 0021W, Oil and Gas Withholding Statement to interest          DR 0021S on page 11. If no balance of severance tax is 
owners by March 1 of each year. This form lists the gross        due, an extension for filing is not required. 
income and the amount of severance tax the producer              The DR 0021S is an extension of time to file your return. It 
has withheld and paid to the state from your royalty or          is not an extension of time to pay severance tax.
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 www.TaxColorado.com – the official Taxation Web 
governments (cities and counties). You are allowed a credit      site.
against severance tax of 87.5% of your share of ad valorem 



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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.
                                                                Use the correct tax year form when filing a Colorado 
Estimated Severance Tax Payments                                  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 month         Taxpayers must complete the DR 0021D, Colorado Oil 
by the 15th day of that month and must be submitted by            and Gas Severance Tax Schedule, and attach it to the 
Electronic Funds Transfer (EFT). A paper voucher 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 www.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 certificiate.              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 www.TaxColorado.com to download Form 104, which 
can be filed electronically for free using Revenue Online.      If a return should be filed on behalf of an entity, such as 
                                                                  partnership or limited liability company, do not try to file 
See the Form 104 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 tax 
                                                                liability for a tax year to exceed their Colorado severance 
Failure To File                                                 tax credits by $5,000 or more are required to make 
If your severance tax account is open, or if you have           estimated tax payments.
severance income that is reported to the Colorado               To avoid underestimation penalties, corporations must 
Department of Revenue and you do not file a return for the      make severance tax estimated payments by the 15th day of 
tax period, the Department may file a return on your behalf.    the month and must payments be submitted by EFT.
See Exception on page 2. Any severance tax assessed will 
remain due and payable until you file your return or close      For more information, please review FYI General 4.
your account. If you are no longer doing business in the 
State of Colorado, you are required to close your account 
by filing a DR 1102, Account Change or Closure Form.



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                                          Colorado Severance Tax

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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.
                                                                 Refund or Balance Due
Controlled group: corporations, family group, 
or other type of group                                           Line 7 Overpayment
In the case of a controlled group of corporations as defined     Subtract line 3 from line 6 and enter the difference on line 
in section 613A of the Internal Revenue Code where more          7. The Department will send you a refund check for this 
than one member of the group is subject to the severance         amount if your form is properly completed.
tax, the tax must be jointly computed and the severance          Line 8 Refund
tax return must be jointly filed under the name of the           Enter the amount from line 7 that you wish to have 
principal taxpaying corporation. DR 0021AS, available at         refunded. The Department can deposit your refund 
www.TaxColorado.com must be attached.                            directly in to your account at a U.S. bank or other financial 
Joint Returns                                                    institution (such as a mutual fund, brokerage firm, or credit 
A married couple must file a joint return even if there is no    union) in the United States.
income reportable by one of the spouses. A family (man and/      Line 9 Refund Applied to Future Period
or woman with minor children), when more than one member         Enter on line 9 the amount of overpayment, if any, you wish 
of the family is subject to the severance tax, must compute the  credited to estimated severance tax payment for next year.
severance tax on one combined return filed under the parent(s) 
Social Security number. Note: parties to a Civil Union should    Line 10 Tax You Owe
refer to federal tax law to determine the correct filing status. If line 3 is more than line 6, you have additional tax to pay. 
                                                                 Subtract line 6 from line 3 and enter the difference on 
Social Security or Colorado Account Number                       line 10. This is the amount you owe. Attach to your return 
Individuals must use a Social Security number as the             a check or money order in this amount payable to the 
Colorado account number. Business entities must                  Colorado Department of Revenue. Be sure to write your 
provide the Colorado account number and the Federal              Social Security number or Colorado account number 
Employer Identification Number (FEIN). Whether you are           on your check or money order to ensure credit for 
an individual or a business entity, once you have been 
                                                                 your payment.
assigned a Colorado account number by the Colorado 
Department of Revenue, use the Colorado account number           Line 11 Interest
on all returns and correspondence submitted to the               If the return is filed after the due date, interest at the 
Department. For Privacy Act Notice, see FYI General 2.           current statutory rate will accrue on any balance of tax due 
                                                                 until paid. The interest rate is 6% per year if we bill you and 
Tax and Credit                                                   your payment is made more than 30 days after you receive 
First, complete schedule DR 0021D to calculate your              your bill. If you pay your tax with your return or within 30 
severance tax.                                                   days of receiving a bill, the interest rate is 3% per year. 
                                                                 Enter the amount of late filing interest on line 11.
Line 1 Oil and Gas Severance Tax
Enter your net tax from line 5 of schedule DR 0021D.             Line 12 Penalty
                                                                 The penalty on any late filed return with a balance of tax 
Line 2 Impact Assistance Credit                                  due is $30 or 30% of the balance of tax due, whichever is 
A credit against the severance tax is allowed with respect 
                                                                 greater. Enter the amount of late filing penalty on line 12.
to contributions to local government that are deemed to be 
necessary because of a new severance operation or the            Line 13 Estimated Tax Penalty
increase in production at an existing operation. The amount  Corporations that underpay the estimated tax must enter 
of the credit must be certified by the Executive Director        the penalty due from the DR 0206.
of the Department of Local Affairs. Enter your impact 
assistance credit for the year on line 2.                        Be sure to sign your return! If filing a joint return, both 
                                                                 spouses must sign. 
Line 3 Net Tax
Subtract line 2 from line 1, and enter the difference on line    To ensure proper processing, please include your 
                                                                 account number on the return.
3. If line 2 is larger than line 1, enter zero.



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                                                                                                   Departmental Use Only
DR 0021 (08/28/13) 
COLORADO DEPARTMENT OF REVENUE 
Denver CO  80261-0006                              Colorado
www.TaxColorado.com
                                         Severance Tax–Oil and Gas 
(7001)                                             DR 0021

2013
-or-
Fiscal Year Beginning (MM/DD)            Ending (MM/DD/YY)                                  *130021==19999*
                                , 2013
Last Name (or Corporation Name)                                  First Name                                 Middle Initial

                                Date Deceased (MM/DD/YY)     SSN                        Colorado Account Number
  Deceased             Yes
Spouse Last Name (see controlled group definition)               Spouse First Name                          Middle Initial

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

City                                               State         ZIP               Telephone
                                                                                   (              )

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 form                  Round To The 
                       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
                                                                                        
                       Routing Number                                Type:         Checking          Savings
     Direct
     Deposit           Account Number



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                                                                                       *130021==29999*

 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 Telephone 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 
Based on your accounting method (cash or accrual             income or not, including deferred amounts if they are 
basis), use the amounts listed on the DR 0021W you           reported on the federal income tax return.
received to complete DR 0021D. If you disagree with the      Reporting Ad Valorem Tax. (This information 
information provided by a producer/first purchaser,          applies to the following examples.)
you must request a corrected DR 0021W prior to 
completing the DR 0021D. Round all amounts to whole            2011 — year of oil or gas production.
dollars.                                                       Dec. 2012 — ad valorem tax levy  
                                                              assessed on 2011 production ............................$1,000
Column
(A)  Producer Name. Enter in column (A) the name of            April 2013 — ad valorem tax  
     the producer/first purchaser from each DR 0021W. All     paid on 2011 production ....................................$1,000
     information entered on form DR 0021D must have a 
                                                               Ad valorem tax related to 2011 
     form DR 0021W included with the return.
                                                              production from stripper wells ...............................$250
(B)  Gross Income. Enter in column (B) the gross income 
                                                             Cash-Basis Taxpayers
     as reported on DR 0021W. This is your share of          Report only ad valorem tax (on production) actually paid 
     the gross income received or accrued on oil or gas      to the county assessor during the severance tax year. 
     production.                                             Payments to operators of wells do not qualify, only actual 
(C)  Gross Income Attributable To Stripper Well              payments to the assessor. If a payment is skipped during 
     Production. Enter in column (C) the gross income        a tax year, (for example, delinquent) no claim for tax is 
     attributable to stripper well production as reported on allowed. Catch-up or double payments must all be claimed 
     the DR 0021W.                                           in the year paid and cannot be carried back or forward.
(D)  Net Gross Income. Enter in column (D) the net           Example 1. Taxpayer files a severance tax return for the 
     gross income by subtracting the stripper well gross     calendar year 2011 or fiscal year ending in 2011 based 
     income listed in column (C) from the gross income       upon information given above.
     listed in column (B).                                   Result: Taxpayer cannot claim ad valorem tax on 2011 
(E)  Ad Valorem Tax.Enter in column (E) the ad valorem       return since the tax was not paid in the taxpayer’s tax year.
     tax as reported on the DR 0021W. This is the amount     Example 2. Taxpayer files a severance tax return for the 
     paid or accrued to Colorado local governments in        calendar year 2013 or fiscal year ending April or later in 
     the taxable year on oil and gas production. Do not      2013.
     include ad valorem tax on buildings, improvements,      Result: Since the tax was paid in the tax year, 2013, 
     or equipment. A percentage of ad valorem tax is         taxpayer may report ad valorem tax of $750.
     allowed as a reduction to the severance tax.
                                                             Calculation:
(F)  Ad Valorem Tax Attributable To Stripper Well             Ad valorem tax paid in tax year            $1,000
     Production. Enter in column (F) the ad valorem tax 
     attributable to stripper well production as reported on  Less ad valorem tax related to stripper-well 
     the DR 0021W.                                            production                                  ($250)
(G)  Net Ad Valorem Tax. Enter in column (G) the net          Total ad valorem tax reported on 
     ad valorem tax by subtracting the stripper well ad       2013 return                                $750
     valorem tax listed in column (F) from the ad valorem 
                                                             Accrual Basis Taxpayers
     tax listed in column (E).                               Report only ad valorem tax (on production) levied, or 
                                                             assessed, within the severance tax year. In November 
**Note** Reporting revenue and ad valorem taxes in           or December, depending upon the year, the Colorado 
the correct tax year is critical to filing a correct return. counties set the mill levy for assessment of ad valorem tax 
Please review the following information.                     on the prior year’s oil and gas production. The ad valorem 
                                                             tax is not accruable until the amount is established on 
Cash or Accrual Basis. Oil and gas revenue and related 
                                                             that date.
ad valorem tax must be reported on a basis consistent 
with the basis used for filing your federal income tax       Example 3.  Taxpayer files an accrual basis severance tax 
return. Thus, if you are a cash-basis federal taxpayer       return for calendar year 2012.
(this applies to most individuals), reporting income when    Result: Since the levy/assessment date is in the tax year, 
received and deductions when paid, you must report the       2012, taxpayer may report ad valorem tax of $750.



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Calculation:                                                  Line 1 Net Gross Income
Ad valorem tax assessed in tax year $1,000                    Total all amounts in column (D).
Less ad valorem tax related to stripper-well                  Line 2 Tax
Production                                    ($250)          Compute the tax on the income on line 1 using the tax rate 
Total ad valorem tax reported on                              schedule. In the case of a controlled group of corporations 
2012 return                                   $750            as defined in section 613A of the Internal Revenue Code 
                                                              or 
Example 4. Taxpayer files an accrual basis severance tax      a family consisting of a man, woman and/or their 
                                                              minor children, where more than one member of the group 
return for calendar year 2013.
                                                              or family is subject to the severance tax, the tax must be 
Result: Taxpayer cannot claim any ad valorem tax on this      jointly determined and filed. In the case of a controlled 
return since the accrual date is not within the tax year.     group of corporations, attach the DR 0021AS (Affiliation 
(Taxpayer could report the ad valorem tax assessed on         Schedule) to the return.
a fiscal year 2013 return that includes the levy date. An 
example would be July 2012–June 2013 fiscal year.)            Line 3 Net Ad Valorem Tax
                                                              Total of net ad valorem taxes entered in column (G). Check 
Short Period Returns                                          whether your accounting method is on a cash-basis or 
Because severance tax requires filing periods consistent      accrual basis [See instructions for column (E).]
with federal income tax filing years, some companies may 
have to file short period severance tax returns to match      Line 4 Ad Valorem Tax Credit
their federal filings. The same ad valorem rules apply. If no Enter 87.5% of line 3.
payment (cash -basis) or accrual date (accrual basis) falls   Line 5 Net Tax on Oil and Gas Income
within the short tax period, no claim for ad valorem tax is   Enter the difference of line 2 less line 4. (If line 4 is larger, 
allowed. (Also, if the levy or payment date does fall in the  enter 0.) Enter here and on line 1 of the DR 0021.
short period, all the tax applies to only that short period.)
                                                              Make sure you carry the correct totals from the DR 
Example 5. A cash basis taxpayer files a severance tax        0021D to the DR 0021. Please check your math.
return for the short period of August 2012– December 
2012.
                                                              To expedite the processing of your severance tax 
Result: Taxpayer cannot claim any ad valorem tax; the tax     return, attach all documentation to support ad valorem 
payment date is not within the short filing period.           taxes, gross income and severance tax withheld.
Example 6. An accrual basis taxpayer files a severance        Mail your severance tax return and payment, if any, 
return for the short period of August 2012–December 2012.     separately from your Colorado income tax return or any 
Result: Since the accrual date is within the short period,    other tax return. 
taxpayer may claim all ad valorem tax of $750.
Calculation:
Ad valorem tax assessed in tax year $1,000
Less ad valorem tax related to stripper-well 
production                          ($250)
Total ad valorem tax reported on 
short period return                           $750



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DR 0021D (08/28/13)
COLORADO DEPARTMENT OF REVENUE        Colorado Oil And Gas                          *130021D=19999*
Denver CO 80261-0006 
www.TaxColorado.com                Severance Tax Schedule
                                      (Attach to Form 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 form 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 (08/02/13) 
COLORADO DEPARTMENT OF REVENUE                             Extension Of Time For Filing Colorado  
Denver CO 80261-0008 
www.TaxColorado.com
                                                           Oil And Gas Severance Tax Return

Colorado severance tax returns are due to be filed 3½                      If after the original due date of the return it is found that the 
months after the close of the tax year.                                    amount paid is insufficient to meet the 90% requirement, 
An automatic six-month extension of time for filing the                    additional payment should be made as soon as possible 
Colorado severance tax return is allowed for all taxpayers.                to reduce accumulation of penalty and interest. Make such 
However, an extension of time to file is not an extension                  payment with the DR 0021S.
of time to pay the tax. If at least 90% of the net tax liability           Be sure to round your payment to the nearest dollar. The 
is not paid by the original due date of the return, penalty                amount on the check and the amount entered on the 
and interest will be assessed. If 90% or more of the net tax               payment voucher must be the same. This will help maintain 
liability is paid by the original due date of the return and the  accuracy in your tax account.
balance is paid when the return is filed by the last day of the            Submit the DR 0021S with payment to:
extension period, only interest will be assessed.
                                                                                                 Colorado Department of Revenue 
Use the DR 0021S to make a payment that must be made                                             Denver, CO 80261-0008
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.

   DETACH FORM  
   ON THIS LINE                                            Photocopy for your records.
                            Cut here and send only the coupon below. Help us save time and your tax dollars.
                                       DR 0021S (08/28/13) 
(7040) COLORADO DEPARTMENT OF REVENUE                      2013 Extension Payment Voucher for Colorado 
                                       www.TaxColorado.com Oil and Gas Severance Tax Return                                                                            
Return this voucher 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 voucher.
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

                    IF NO PAYMENT IS DUE, DO NOT FILE THIS FORM.
                    The State may convert your check to a one time electronic banking transaction. Your bank account may be debited as early as            Amount Owed
                    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.
   *130021S=19999*                                  (Do not write in space below)                                                                       $             .00



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COLORADO DEPARTMENT OF REVENUE
Denver, CO  80261-0006 
www.TaxColorado.com

                                           Secure Messaging
Contact Department of Revenue support staff electronically through Revenue Online. This service is secure and 
                       confidential. Visit www.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 www.TaxColorado.com

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






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