DR 0096 (08/28/13)
COLORADO DEPARTMENT OF REVENUE                                                                                             *130096==19999*
Business Tax Accounting, Room 208 
PO Box 17087 
Denver, CO 80217-0087
(303) 238-SERV (7378)

                                      Request For Tax Status Letter

In accordance with the provision of § 38–25.5, C.R.S., I hereby request that the Department if Revenue issue a tax 
status letter.
Last Name of Taxpayer/DBA                                         First Name of Taxpayer/DBA                                              Middle Initial

Address                                                                                                   City                   State    Zip

Mailing Address                                                                                           City                   State    Zip

Colorado Account Number(s)                FEIN                                                                 Phone Number
                                                                                                               (          )

                                                                  Type of Taxes

                        List only taxes that are remitted to the Colorado Department of Revenue.*

 Corporate Income                     Consumer Use                       SCFD Sales                                              County Sales

 State Sales                          State Withholding                  Football Sales                                          Retailers Use

 City Sales                           RTD Sales                          County Lodging                                          Severance
Make Check Payable To:    Department of Revenue                                                                Fee: $7.00 Per Tax
                          To Be Paid Before Issuance of the Clearance                                          Total Remitted
                          Please make a copy for your records.
The state may convert your check to a one time electronic banking transaction. Your bank account may 
be debited as early 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.
*Tax status letters are not available for individual income tax. Do Not send this form or payment as a request for               an individual income 
 tax status letter.

If liability for any other tax exists and reports have not been filed, the tax may be assessed at any time. The issuance of this letter does 
 not fix, abate, modify, or cancel any liability or payment of money due or performance of an obligation to the State of Colorado.

I declare under the penalty of perjury in the second degree that I am a duly authorized officer of the corporation for which this tax status 
letter is requested and that I am acting in my official capacity in making this request.

Authorization/Power of Attorney must be attached to this request if applicable.
Name                                                                Title

Signature                                                                                                                  Date (MM/DD/YY)