Departmental Use Only
                                     DR 0021PE (06/19/14)
                                     COLORADO DEPARTMENT OF REVENUE
                                     Denver CO 80261-0006 
                                     www.TaxColorado.com
                                     (7032)

                                                               Estimated Colorado Oil  
        *140021PE19999*
                                                               Shale Severance Tax
Calendar Year (YYYY)                 Fiscal Tax Year Beginning (MM/YY)       Fiscal Tax Year Ending (MM/YY)

Colorado Account Number                                    FEIN

Last Name or Business Name                                             First Name                             Middle Initial

Address                                                                City                         State  Zip

Foreign Country                      Due Date (MM/DD/YY)

Signature of Officer or Agent

1. Oil Shale Tax                                                                                    $                                                                             00

2. Credits                                                                                          $                                                                             00

3. Payment Due — Line 1 minus Line 2                                                                $                                                                             .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 to and make checks payable to:
                                     Colorado Department of Revenue
                                     Denver, CO 80261-0006

                Instructions for Estimated Colorado Oil Shale Severance Tax

Corporations that must pay Estimated Severance Tax             Due Dates of Payments
Every corporation subject to severance tax must pay            Estimated tax is due on or before the 15th day of the 
estimated severance tax if its severance tax liability for     4th, 6th, 9th and 12th month of the taxable year. The 
the tax year is expected to exceed its severance tax           corporation may elect to prepay any installment due.
credits by $5,000 or more. If payments are submitted via 
Electronic Funds Transfer (EFT), a paper voucher for           Credits
these tax payments is not required; the EFT transaction        Any overpayment of severance tax from a prior quarter 
is the filing.                                                 or year may be claimed as a credit to this quarter's 
                                                               estimated tax.
Authorization to Submit EFT Payments
If you are not currently set up to send EFT payments, 
you may obtain information (DR 5782) and an application 
(DR 5785) at www.TaxColorado.com