Departmental Use Only
                                                DR 0133 (07/09/14)
                                                COLORADO DEPARTMENT OF REVENUE
                                                Denver, CO 80261-0009
                                                www.TaxColorado.com

                                                    Passenger Mile Tax Return
          *140133V219999*
                                                                     See page 2 for instructions

Account Number                                                    Period (MM/YY - MM/YY)                 Due Date (MM/DD/YY)
                                                                                          -
Taxpayer Last Name or Business Name                               First name                                  Middle Initial

SSN                                  Email Address                                       FEIN
                                                                                                              5140-100
Signed Under Penalty Of Perjury In The Second Degree.
Signature                                                                    Date (MM/DD/YY)  Telephone Number
                                                                                              (         )

1. Passenger mile tax (DR 7011)                                                               (100)                         00

2. Passenger mile tax paid at ports                                                           (925)                         00

3.  Refund: only if line 2 is more than line 1                                                (410)                         00

4.  Balance due if line 1 is more than line 2                                                                               00

5. Penalty                                                                                    (200)                         00

6. Interest                                                                                   (300)                         00

7. Amount Owed                                                       Paid by EFT              (355)
                                                                                                    $                       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 80261-0009

                Passenger Mile Tax Return Instructions
            A return must be filed for each period even if no operations were conducted in Colorado.

Line 1:  Enter passenger mile tax from form DR 7011.           Line 5:  If the return is filed after the due date, late filing 
       Follow detailed instructions on that form to                    penalty is due as follows:
       calculate passenger mile tax. Indicate a zero (0)  
       if you did not operate in Colorado.                             Passenger Mile Tax Penalty — 3% per month 
                                                                       multiplied by the amount (on line 1, less line 2) is 
       Note:  The passenger mile tax is calculated as                  due. Example: Line 1 passenger mile tax is $100 
       follows:                                                        and line 2 is $50 paid at the port. The penalty due 
                                                                       would be calculated as:
       Number of passengers times the number of 
       Colorado miles times $.001.                                      $100 – $50 = $50
                                                                        .03 x $50 = $1.50
       This calculation is done for each bus and each                   1.50 x Number of months late
       trip. Add all of the trips together for the quarter and 
       record the total on line 1.                             Line 6: If the return is filed after the due date, late filing 
                                                                       interest is due at the current statutory monthly rate 
Line 2:  Credit for passenger mile tax paid at ports must              preprinted on the return, multiplied by the amount 
       be claimed within the reporting period that                     on line 4 for each month the return is late.
       payment was made. Credit is allowed only if a 
       tax liability is reported on this return. No credit is  Line 7:  Add lines 4, 5 & 6 to determine tax due.
       allowed for permit fees such as PUC fees, fuel 
       permit fees, etc. collected at ports.

Line 3:  If line 2 exceeds line 1, refund of the excess will 
       be made. Refunds may be claimed only for the 
       period filed and will not be offset against prior or 
       future tax liabilities. Do not complete line 3 if there 
       is a balance due on line 4.

Line 4:  If line 1 exceeds line 2, enter the balance due. 
       Payment is required with this return.