DR 0021SE (07/24/15) 
                                                      COLORADO DEPARTMENT OF REVENUE 
                                                      Denver, CO  80261-0008 
*150021SE19999*                                       www.TaxColorado.com

                                                      (7042)

                           Extension of Time for Filing Colorado  
                                                  Oil Shale Severance Tax Return

Colorado severance tax returns are due on or before              Use the DR 0021SE to make a payment that must be 
the 15th day of the fourth month following the end of the        made by the original due date of the return to meet the 
taxable year.                                                    90% requirement.

An automatic six-month extension of time for filing the          If after the original due date of the return it is found that the 
Colorado severance tax return is allowed for all taxpayers.      amount paid is insufficient to meet the 90% requirement, 
However, an extension of time to file is not an extension        additional payment should be made as soon as possible 
of time to pay the tax. If at least 90% of the net tax liability to reduce accumulation of penalty and interest. Make such 
is not paid by the original due date of the return, penalty      payment on the DR 0021SE.
and interest will be assessed. If 90% or more of the net tax 
liability is paid by the original due date of the return and the Submit the DR 0021SE with payment to:
balance is paid when the return is filed by the last day of                  Colorado Department of Revenue
the extension period, only interest will be assessed.                        Denver, CO 80261-0008

Round all amounts to the nearest dollar
1. Tentative amount of tax for the taxable year after reduction  
  for the impact assistance credit (if any)                                                          $                   00

2. Less estimated tax payments                                                                       $                   00
3. Balance to be remitted with this request for extension, line 1 minus line 2.  
  Enter amount of payment below. Claim credit for this payment on line 12 of DR 0020E                $                   00
                                                      If no payment is due, do not file the DR 0021SE
For tax period beginning: (MM/DD/YY)                  Ending: (MM/DD/YY)

Return this form 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 Employment Identification 
Number and “DR 0021SE” on your check or money order. Do not send cash. Enclose, but do not staple or attach your 
payment with this form.
Last Name or Business Name                            First Name                                     Middle Initial Colorado Account Number

Address                                               City                   State   Zip               FEIN
    
Foreign Country

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 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.

                                                                                     Amount Owed     $            .00