Departmental Use Only
                                                DR 0022 (06/18/14)
                                                COLORADO DEPARTMENT OF REVENUE
                                                Denver CO 80261-0006 
                                                www.TaxColorado.com
                                                (7003)

                                                                   Colorado Molybdenum Ore  
        *140022==19999*
                                                                     Severance Tax Return
Taxable Quarter                                                                             Year (YYYY)
                             Jan-Mar              Apr-June          Jul-Sept    Oct-Dec
Colorado Account Number                                              FEIN

Last Name or Business Name                                                    First Name                               Middle Initial

Address                                                                                       Phone Number 
                                                                                              (           )
City                                                  State ZIP              Foreign Country

Check if final return    

Mine Name as it filed with CO Division of Mines County or Counties in which Mine is Located Number of Tons of Ore Mined

Round all amounts to the nearest dollar

1. Total tons mined                                                                         1

2. Exemption                                                                                2                          625,000

3. Total taxable tons mined (line 1 minus line 2)                                           3

4. Tax (line 3 x .05)                                                                       4 $                               0 0

5. Impact assistance credit                                                                 5 $                               0 0

6. Net tax, line 4 less line 5 but not less than zero                                       6 $                               0 0

7. Interest on balance due                                                                  7 $                               0 0

8. Penalty on balance due                                                                   8 $                               0 0

                                                                        Paid by EFT
9. Amount Owed, add lines 6, 7 and 8                                                        9 $                               .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.

     *140022==29999*

Last Name of person preparing return                   First Name                               Middle Initial

Address of person preparing return                                                 Phone Number 
                                                                                   (           )
City                                                                               State Zip

Under penalty of perjury in the second degree, I declare that I have examined this return and to the best of my  
knowledge and belief it is true, correct and complete. 
Signature of Taxpayer or Corporate Officer                                         Date (MM/DD/YY)

                                           Mail to and make checks payable to:
                                           Colorado Department of Revenue
                                           Denver, CO 80261-0006
                                                          
Filing Requirements: Every person engaged in             Impact Assistance Credit: A credit against the 
the severance of molybdenum ore is liable. The return is severance is allowed with respect to contributions of 
due on or before the 15th day following the end of each  property or money to units of local government for 
calendar quarter. A paper form is not required if only the tax  planning, deemed to be necessary because of new 
due on line 4 is being paid in full by an EFT payment.   severance operation or the increase in production at an 
                                                         existing operation. You must attach a certification from the 
Tax Rate: The rate of tax for each calendar year quarter executive director of the Department of Local Affairs to 
shall be $.05/ton of molybdenum ore. The first 625,000   claim this credit.
tons of ore shall be exempt from the tax. 
                                                         Interest and Penalty: If the return is filed after the due 
Information: Forms and information are available at      date, interest at the current statutory rate will accrue on any 
www.TaxColorado.com                                      balance of tax due until paid. A penalty of the larger of $30 
                                                         or 30% of the balance of tax due will be assessed on any 
                                                         delinquently filed return.