Departmental Use Only
                                                DR 0022X (06/20/14) 
                                                COLORADO DEPARTMENT OF REVENUE 
                                                Denver, CO  80261-0006 
                                                www.TaxColorado.com

                                                (7104)

                                                        Amended Colorado Molybdenum  
        *140022X=19999*
                                                                    Ore Severance Tax Return
Taxable Quarter (MM/YY-MM/YY)                                                                     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 $                               00

  5. Impact assistance credit                                                                   5 $                               00

  6. Net tax, line 4 less line 5 but not less than zero                                         6 $                               00
     Stop here to let the department calculate your refund or balance due. Otherwise, manually complete the return yourself and 
Stop continue with line 7.

  7. Enter the net tax from your original return or as previously adjusted                      7 $                               00
Compute the amount you owe

  8. Additional tax due, line 6 minus line 7, but not less than zero                            8 $                               00

  9. Interest on additional tax                                                                 9 $                               00

10. Penalty on additional tax                                                                  10 $                               00

                                                                           Paid by EFT
11. Total amount due, add lines 8, 9 and 10                                                    11 $                               .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.

     *140022X=29999*

Compute your refund

12. Refund claimed with this return, line 7 minus line 6, but not less than zero 12       $                      00

                                   Routing Number                        Type:   Checking       Savings
     Direct
     Deposit                       Account Number
Reason for Amendment

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

                               Amended Colorado Molybdenum 
                                          Ore Severance Tax Return

                                          DR 0022X Instructions

The  Amended Colorado Molybdenum  Severance  Tax                The routing number must be nine digits.  The  account 
Return (DR 0022X) is required to be used when correcting        number  can  be  up  to  17  characters  (both  numbers  and 
your Colorado Molybdenum Severance Tax Return                   letters). Include hyphens but omit spaces and special symbols.   
(DR 0022).                                                      You should contact your financial institution to ensure your 
                                                                deposit will be accepted and to obtain the correct routing and 
Statute Of Limitations
                                                                account numbers. This is especially important if you want your 
The statute of limitations for filing a Colorado severance tax  refund deposited to a savings account at a credit union. The 
claim for refund is generally three years from the due date     Department of Revenue is not responsible for a lost refund if 
of the original return or three years from the date of last tax you enter the wrong account information. Any refund claim 
payment for the year involved, whichever is later.              that, for any reason, cannot be deposited into the account 
                                                                specified will be issued and mailed in check form instead.
Colorado Account Number
Enter your Colorado account  number and your Federal            Interest
Employer  Identification  Number  in  the  spaces  provided.    If the return is amended after the original due date of the 
Individuals, enter your Social Security number.                 return, interest at the applicable statutory rate will accrue on 
                                                                any balance of tax due until paid interest rates are published 
Lines 1 through 7 — Compute the net tax from your               on our web site at www.TaxColorado.com
original return or as previously adjusted.
                                                                Penalty
Lines 8 through 11 — Compute the amount you owe.                The penalty on any balance of tax due is $30 or 30% of 
Write your Colorado account number or Federal Employer          the balance of tax due, whichever is greater.
Identification Number on your check. Enclose, but do not 
attach your payment with DR 0022X.                              Reason for amended return
                                                                Attach an explanation and any documentation needed to 
Line 12 — Compute your refund.                                  substantiate the changes reported on the amended return.

Direct Deposit                                                  Forms and Information
The department can deposit your refund directly into your       If you have any questions you may call the Department of 
account at a U.S. bank or other financial institution (such as  Revenue at (303) 238-SERV(7378) or see our Web site at 
a mutual fund, brokerage firm or credit union) in the United    www.TaxColorado.com for forms and information.
States.