Departmental Use Only                       DR 0021X (06/18/14) 
                                                     COLORADO DEPARTMENT OF REVENUE 
                                                     Denver, CO  80261-0006 
                                                     www.TaxColorado.com
                                                     (7102)

                                                                Amended Colorado Oil and Gas  
       *140021X=19999*                                                      Severance Tax Return

For Taxable Year (YYYY)                    Fiscal Tax Year Beginning (MM/YY)               Fiscal Tax Year Ending (MM/YY)

Last Name or Business Name                                                      First Name                               Middle Initial

                           SSN                                              Colorado Account Number
Deceased                Yes
Spouse’s Last Name (see controlled group definition)            First Name                                               Middle Initial

                           SSN                                              FEIN
Deceased                Yes
Address

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
                                                                                                                          
                                                                                                                  Round to the  
Tax and Credit — Complete schedule DR 0021D first. Attach the DR 0021D to this 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 forms DR 0021W                                                      4  $                      00

5. Estimated tax and extension payments                                                               5  $                      00
6. Total Prepayments, add lines 4 and 5
                                                                                                      6  $                      00
     Stop here to let the department calculate your refund or balance due. Otherwise, manually complete the return 
Stop yourself and continue with line 7. 

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

8. Enter the overpayment from your original return or as previously adjusted                          8  $                      00

9. If line 3 is larger than line 6, enter the amount owed                                             9  $                      00

10. Enter the amount owed from your original return or as previously adjusted                         10 $                      00

     *140021X=29999*

Compute the amount you owe

11. Line 8 minus line 7, but not less than zero                                           11    $                00

12. Line 9 minus line 10, but not less than zero                                          12    $                00

13. Additional tax due, total of lines 11 and 12                                          13    $                00

14. Interest due on additional tax                                                        14    $                00

15. Penalty due                                                                           15    $                00

16. Estimated tax penalty due                                                             16    $                00
                                                                
17. Payment due with this return, add lines 13 through 16          Paid by EFT            17
                                                                                                $                .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.
Compute your refund

18. Line 7 minus line 8 but not less than zero                                           18     $                00

19. Line 10 minus line 9, but not less than zero                                         19     $                00
20. Refund claimed with this return, total of lines 18 and 19  
(Do not include this amount on line 20)                                                   20    $                00

21. Overpayment credited to next year’s estimated tax                                     21    $                00

                                   Routing Number                          Type:       Checking      Savings
     Direct
     Deposit                       Account Number

Reason for Amendment

Last Name of person preparing return                            First Name                                     Middle Initial

Address of person preparing return                                         Phone Number
                                                                           (          )
City                                                                                              State Zip

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)

Mail to and make checks payable to:
                                        Colorado Department of Revenue
                                        Denver, CO 80261-0006

                  Amended Colorado Oil and Gas Severance Tax Return

                            DR 0021X Instructions

The Amended Colorado Oil and Gas Severance                    How do I use Direct Deposit?
Tax Return (DR 0021X) is required to be used when             The routing number must be nine digits. The account 
correcting your Colorado Oil and Gas Severance Tax            number can be up to 17 characters (both numbers and 
Return (DR 0021).                                             letters). Include hyphens but omit spaces and special 
                                                              symbols.
Statute of Limitations
The statute of limitations for filing a Colorado severance 
tax claim for refund is generally three years from the due 
date of the original return or three years from the date of 
last tax payment for the year involved, whichever is later.

Refund for Deceased Taxpayer
To request a refund for a deceased taxpayer, write 
“deceased” across the top of the return and the date of 
death next to the deceased person’s name. Additionally, 
you must sign the return and write “filling as surviving 
spouse” or “filling as legal representative” by your          You should contact your financial institution to ensure 
signature.                                                    your deposit will be accepted and to obtain the correct 
                                                              routing and account numbers. This is especially important 
Any person other than the surviving spouse who files          if you want your refund deposited to a savings account 
a return and requires a refund on behalf of a deceased        at a credit union. The Department of Revenue is not 
person must attach a copy of the death certificate and the    responsible for a lost refund if you enter the wrong 
DR 0102, Claim for Refund for Deceased Taxpayer.              account information. Any refund claim that, for any reason, 
                                                              cannot be deposited into the account specified will be 
Colorado Account Number                                       issued and mailed in check form instead.
For business accounts, enter your Colorado account 
number and your  Federal Employer Identification Number       Interest
(FEIN) in the spaces provided. For individuals, enter your    If the return is amended after the original due date of the 
Social Security number.                                       return, interest at the applicable statutory rate will accrue 
                                                              on any balance of tax due until paid. Interest rates are 
Lines 11 through 17                                           published on our web site at www.TaxColorado.com
Compute the amount owed to the state on the amended 
return. Any decrease in the amount of the overpayment 
(line 11) or increase in the amount owed (line 12) will       Penalty
                                                              The penalty on any balance of tax due is $30 or 30% of 
indicate that an amount is owed with the amended return. 
                                                              the balance of tax due, whichever is greater.
To pay the amount you owe, write your Colorado account 
number or Federal Employer Identification Number (FEIN) 
on your check. Enclose but do not attach your payment         Reason for amended return
with DR 0020CX.                                               Attach an explanation and any documentation, including 
                                                              schedule DR 0021D, and/or DR 0021PD needed to 
                                                              substantiate the changes reported on the amended return.
Lines 18 through 21 
Compute the amount of credit available on the amended 
return. Any increase in the amount of the overpayment         Forms and Information
(line 18) or decrease in the amount owed (line 19)            If you have any questions you may call the Department of 
will indicate that an overpayment is available with the       Revenue at (303) 238-SERV(7378) or see our Web site at 
amended return. The overpayment can be credited to            www.TaxColorado.com for forms and information.
estimated tax (line 21) for the tax year following the period 
on the amended return, or can be requested as a refund 
(line 20).

Direct Deposit
The department can deposit your refund directly into your 
account at a U.S. bank or other financial institution (such 
as a mutual fund, brokerage firm, or credit union) in the 
United States.