Departmental Use Only
                                                   DR 0020EX (07/09/14)
                                                   COLORADO DEPARTMENT OF REVENUE
                                                   Denver CO 80261-0006 
                                                   www.TaxColorado.com
                                                   (7106)

                                                              Amended Colorado Oil Shale
        *140020EX19999*                                       Facility Severance Tax Return
Taxable Year Beginning (MM/DD/YY)                                       Taxable Year Ending (MM/DD/YY)

Last Name or Business Name                         First Name                               Middle Initial Colorado Account Number

Address                                                                                                    FEIN

City                                                                    State    Zip                       Phone Number
                                                                                                           (          )
Foreign Country

If this is a final return, check this box.         
                                                •
Name of facility as identified with the Colorado Department of Natural Resources 

County or counties in which operation is located

                                                                                                      Round to the Nearest Dollar

1.     Total sales price of shale oil                                                                   1                         0 0

Less direct and indirect expenditures for:

2.     Equipment and machinery                                                                          2                         0 0
3.     Fragmenting, crushing, conveying, beneficiating, pyrolysis, retorting, refining and 
     transporting                                                                                       3                         0 0

4.     Royalty payments                                                                                 4                         0 0

5.     Total of lines 2,3 and 4                                                                         5                         0 0

6.   Gross proceeds, line 1 minus line 5                                                                6                         0 0
7.   Enter the sales price of shale oil from the production of the first 15,000 tons
       per day of oil shale or 10,000 barrels per day of shale oil, whichever is greater                7                         0 0

8.     Taxable gross proceeds, line 6 minus line 7                                                      8                         0 0

9.     Tax on taxable gross proceeds. Use the tax rate schedule in the instructions                     9                         0 0

10.  Impact assistance credit                                                                          10                         0 0

11.    Net tax, line 9 minus line 10 but not less than zero                                            11                         0 0

12.    Estimated tax and extension payments                                                             12                        0 0
               Stop here to let the Department calculate your refund or balance due. Otherwise, manually complete the return 
     Stop      yourself and continue with line 13

13.  If line 12 is larger than line 11, enter your overpayment                                          13                        0 0

     14.  Enter the overpayment from your original return or as previously adjusted                     14                        0 0

     *140020EX29999*

15.   If line 11 is larger than line 12, enter the amount owed                                  15                                                                                 0 0

16.  Enter the amount owed from your original return or as previously adjusted                  16                                                                                 0 0
Compute The Amount You Owe

17.    Line 14 minus line 13, but not less than zero                                           17                                                                                  0 0

18.    Line 15 minus line 16, but not less than zero                                           18                                                                                  0 0

19.  Additional tax due, total of line 17 and 18                                                19                                                                                 0 0

20.  Interest due on additional tax                                                             20                                                                                 0 0

21.  Penalty due                                                                                21                                                                                 0 0

22.  Estimated tax penalty due                                                                  22                                                                                 0 0

23.  Amount owed with this return, add lines 19 through 22
                                                                                                23 $           .0 0
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 funds, the Department of Revenue may collect the payment amount directly from your bank account electronically. 
Compute Your Refund

24.  Line 13 minus line 14, but not less than zero                                             24                                                                                  0 0

25.  Line 16 minus line 15, but not less than zero                                             25                                                                                  0 0

26.  Refund claimed with this return, total of lines 24 and 25                                  26                                                                                 0 0

27.  Overpayment credited to next year's estimated tax (Do not include this amount on line 26)  27                                                                                 0 0

                               Routing Number                      Type:             Checking        Savings
        Direct
        Deposit                Account Number
Reason For Amendment (Required)

Tax Rates
 First Year of Production                                                                                      1%
 Second Year of Production                                                                                     2%
 Third Year of Production                                                                                      3%
 Fourth Year of Production                                                                                     4%
Under penalty of perjury in the second degree, I declare that I have examined this return and to the best if my knowledge 
and belief it is true, correct, and complete.
Signature of Taxpayer or Corporate Officer                                                               Date (MM/DD/YY)

Last Name (Preparer of Return)                       First Name (Preparer of Return)                           Middle Initial

Address                                                                                            Phone Number
                                                                                                   (          )
City                                                                                               State Zip

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

                       Amended Colorado Oil Shale Facility
                                      Severance Tax Return

                                      DR 0020EX Instructions

The Amended Colorado Oil Shale Facility Severance           We recommend that you contact your financial institution 
Tax Return (DR 0020EX) is required to be used when          to ensure you are using the correct information and that 
correcting your Colorado Oil Shale Facility Severance       they will honor a direct deposit.  See the sample check 
Tax Return (DR 0020E).                                      below to assist you in finding the account and routing 
                                                            numbers.
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.

Colorado Account Number
Enter your Colorado account number and your Federal 
Employer Identification Number (FEIN) in the spaces         The Department is not responsible for a lost refund if you 
provided. Individuals, enter your Social Security number.   enter the wrong account information. Any refund claim 
                                                            that, for any reason, cannot be deposited into the account 
Lines 17 through 23 Compute the amount owed to the          specified will be issued and mailed in check form instead.
state on the amended return. Any decrease in the amount 
of the overpayment (line 17) or increase in the amount 
owed (line 18) will indicate that an amount is owed with    Interest
the amended return.                                         If the return is amended after the original due date of the 
                                                            return, interest at the applicable statutory rate will accrue 
Lines 24 through 27 Compute the amount of credit            on any balance of tax due until paid. Interest rates are 
available on the amended return. Any increase in the        published on our web site at www.TaxColorado.com
amount of the overpayment (line 24) or decrease in the 
amount owed (line 25) will indicate that an overpayment     Penalty
is available with the amended return. The overpayment       The penalty on any balance of tax due is $30 or 30% of the 
can be credited to estimated tax (line 27) for the tax year balance of tax due, whichever is greater.
following the period on the amended return, or can be 
requested as a refund (line 26)                             Reason for amended return
                                                            Complete the reason for amendment box and attach 
                                                            an explanation and any documentation needed to 
Direct Deposit                                              substantiate the changes reported on the amended return.
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. 

Enter the routing and account numbers and account type 
where indicated. The routing number is 9 digits. Account 
numbers can be up to 17 characters (numbers and/or 
letters).  Include hyphens, but do not enter spaces or 
special symbols.