Departmental Use Only          DR 0021PC (06/18/14) 
                                             COLORADO DEPARTMENT OF REVENUE 
                                             Denver, CO  80261-0006 
                                             www.TaxColorado.com
                                             (7034)
                                                                       Estimated Colorado Coal  
        *140021PC19999*                                                        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. Coal Tax                                                                                         $                                                                             00

2. Credits                                                                                          $                                                                             00

3. Payment Due — Line 1 minus Line 2                                                                $                                                                             .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. 
                                             Mail to and make checks payable to:
                                             Colorado Department of Revenue
                                             Denver, CO 80261-0006

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