Departmental Use Only
                                     DR 0021PA (06/18/14)
                                     COLORADO DEPARTMENT OF REVENUE
                                     Denver CO 80261-0006
                                     www.TaxColorado.com
                                     (7036)

                                                                Estimated Colorado Metallic  
         *140021PA19999*
                                                                Minerals 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                                                            Date (MM/DD/YY)

1. Metallic Minerals Tax                                                                 $                                                                                        0 0

2. Credits                                                                               $                                                                                        0 0

3. Payment Due — Line 1 minus Line 2                                                     $                                                                                        .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 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 Metallic Minerals 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 4th, 
estimated severance tax if its severance tax liability for      6th, 9th and 12th month of the taxable year when tax is 
the tax year is expected to exceed its severance tax            due. The corporation may elect to prepay any installment 
credits by $5,000 or more. If payments are submitted via        due.
Electronic Funds Transfer (EFT), a paper voucher for 
these tax payments is not required; the EFT transaction         Credits
is the filing.                                                  Any overpayment of severance tax from a prior quarter 
                                                                or year may be claimed as a credit to this quarter's 
Authorization to Submit EFT Payments                            estimated tax.
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