Departmental Use Only
DR 0021X (07/31/13) 
COLORADO DEPARTMENT OF REVENUE 
Denver, CO  80261-0006 
www.TaxColorado.com
(7102)

        Amended Colorado Oil and Gas  
                                                                                                  *130021X=19999*
                        Severance Tax Return
For Taxable Year (YYYY)                         Fiscal Tax Year Beginning (MM/YY)           Fiscal Tax Year Ending (MM/YY)
2014                                            04/14                                       04/15
Last Name (or Corporation Name)                           First Name                                                      Middle Initial
lkjlkj                                                     lkjlkj                                                          j
                               SSN                                        Colorado Account Number
Deceased                   Yes  98798797987                               98798987
Spouse’s Last Name (see controlled group definition)      First Name                                                      Middle Initial
9879878                                                    987                                                             987
                               SSN                                        FEIN
Deceased                   Yes  098098098                                 098098
Address
kjjh
City                                                                              State Zip       Phone Number 
kjh                                                                               kjh   kjh       ((303) 890-7896)
                                                                                                                           
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     $                 098098 00

2. Impact assistance credit                                                                        2     $                 0998   00

3. Net tax, line 1 minus line 2 but not less than zero                                             3     $                 098    00
Prepayments

4. Severance tax withheld, attach forms DR 0021W                                                   4     $                 09809  00

5. Estimated tax and extension payments                                                            5     $                 8098   00

6. Total Prepayments, add lines 4 and 5                                                            6     $                 098    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     $                 098    00

8. Enter the overpayment from your original return or as previously adjusted                       8     $                 08     00

9. If line 3 is larger than line 6, enter the amount owed                                          9     $                 098    00

10. Enter the amount owed from your original return or as previously adjusted                      10    $                 345    00

                                                                               *130021X=29999*

Compute the amount you owe

11. Line 8 minus line 7, but not less than zero                                       11 $                       345  00

12. Line 9 minus line 10, but not less than zero                                      12 $                       0980 00

13. Additional tax due, total of lines 11 and 12                                      13 $                       98   00

14. Interest due on additional tax                                                    14 $                       0980 00

15. Penalty due                                                                       15 $                       98   00

16. Estimated tax penalty due                                                         16 $                       098  00

17. Payment due with this return, add lines 13 through 16           Paid by EFT
                                                                                      17 $                       345  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 $                       098  00

19. Line 10 minus line 9, but not less than zero                                      19 $                       0980 00
20. Refund claimed with this return, total of lines 18 and 19  
(Do not include this amount on line 20)                                               20 $                       98   00

21. Overpayment credited to next year’s estimated tax                                 21 $                       098  00

                                   Routing Number 8 9 9 9 9 9 9 9 9     Type:  Checking       Savings
            Direct
            Deposit                Account Number 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

Reason for Amendment
kjhkljhlkjh 
asdfsadfsdfsdf
Last Name of person preparing return                   First Name                                   Middle Initial
lkj                                                    lkj                                                       kj
Address of person preparing return                                     Phone Number 
kjlkj                                                                  ((303))890-7896
City                                                                                          State Zip
kjjhkjh                                                                                       hj    89098
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)
                                                                                         11/11/11
Spouse’s Signature                                                                       Date (MM/DD/YY)
                                                                                         11/11/11
Signature of Corporate Officer                                                           Date (MM/DD/YY)
                                                                                         11/11/11
                                        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 make 
signature.                                                  sure your deposit will be accepted and to obtain the 
                                                            correct routing and account numbers. This is especially 
Any person other than the surviving spouse who files 
                                                            important if you want your refund deposited to a savings 
a return and requires a refund on behalf of a deceased 
                                                            account at a credit union. The Department of Revenue 
person must attach a copy of the death certificate and the 
                                                            is not 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, 
Colorado Account Number                                     cannot be deposited into the account specified will be 
For business accounts, enter your Colorado account          issued and mailed in check form instead.
number and your  Federal Employer Identification Number 
(FEIN) in the spaces provided. For individuals, enter your  Interest
                                                            If the return is amended after the original due date of the 
Social Security number.
                                                            return, interest at the applicable statutory rate will accrue 
Lines 11 through 17 compute the amount owed to              on any balance of tax due until paid.
the state on the amended return. Any decrease in the 
amount of the overpayment (line 11) or increase in the      Penalty
                                                            The penalty on any balance of tax due is $30 or 30% of 
amount owed (line 12) will indicate that an amount is owed 
                                                            the balance of tax due, whichever is greater.
with the amended return. To pay the amount you owe, 
write your Colorado account number or Federal Employer 
Identification Number (FEIN) on your check. Enclose but     January 1 through December 31:        2009 2010 2011 2012 2013

do not attach your payment with DR 0020CX                   Tax due paid without billing          5% 3% 3% 3%     3%
Lines 18 through 21 compute the amount of credit 
                                                            Tax paid within 30 days of billing    5% 3% 3% 3%     3%
available on the amended return. Any increase in the 
amount of the overpayment (line 18) or decrease in the      Tax due paid after 30 days of billing 8% 6% 6% 6%     6%
amount owed (line 19) will indicate that an overpayment 
is available with the amended return. The overpayment       Refunds of less than $5,000           8% 6% 6% 6%     6%
can be credited to estimated tax (line 21) for the tax year Refunds of $5,000 or more and 
                                                                                                  5% 3% 3% 3%     3%
following the period on the amended return, or can be       10% or more of the net tax liability
requested as a refund (line 20).
                                                            Reason for amended return
Direct Deposit                                              Attach an explanation and any documentation, including 
The department can deposit your refund directly into your   schedule DR 0021D, and/or DR 0021PD needed to 
account at a U.S. bank or other financial institution (such substantiate the changes reported on the amended return.
as a mutual fund, brokerage firm, or credit union) in the 
                                                            Forms and Information
United States.                                              If you have any questions you may call the Department of 
                                                            Revenue at (303) 238-SERV(7378) or see our Web site at 
                                                            www.TaxColorado.com for forms and information.