DR 0021SA (07/24/15) 
                                                      COLORADO DEPARTMENT OF REVENUE 
*150021SA19999*                                       Denver, CO  80261-0008 
                                                      www.TaxColorado.com
                                                      (7046)

                           Extension of Time for Filing Colorado  
                           Metallic Minerals Severance Tax Return

Colorado severance tax returns are due on or before              If after the original due date of the return it is found that the 
the 15th day of the fourth month following the end of the        amount paid is insufficient to meet the 90% requirement, 
taxable year.                                                    additional payment should be made as soon as possible 
An automatic six-month extension of time for filing the          to reduce accumulation of penalty and interest. Make such 
Colorado severance tax return is allowed for all taxpayers.      payment on the DR 0021SA.
However, an extension of time to file is not an extension        Be sure to round your payment to the nearest dollar. You 
of time to pay the tax. If at least 90% of the net tax liability must enter 00 after the decimal point. The amount on the 
is not paid by the original due date of the return, penalty      check and the amount entered on the DR 0021SA must 
and interest will be assessed. If 90% or more of the net tax     be the same. This will help maintain accuracy in your tax 
liability is paid by the original due date of the return and the account.
balance is paid when the return is filed by the last day of      Submit the DR 0021SA  with payment to:
the extension period, only interest will be assessed.                        Colorado Department of Revenue
Use the DR 0021SA to make a payment that must be made                        Denver, CO 80261-0008
by the original due date of the return to meet the 90% 
requirement.

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 11 of DR 0020A                $              00
                                                      If no payment is due, do not file the DR 0021SA
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 0021SA” 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