DR 0241 (07/10/13)
COLORADO DEPARTMENT OF REVENUE                                                              *130241==19999*
Denver CO 80261-0009
(303) 205-8205

                                          Application for Fuel Tax  
                                          Exemption Certificate  
                               for Government or Political Subdivision
Taxpayer Name

Address

City                                                                                                       State  Zip

County                                                         City Limits In Which Located (if applicable)

Mailing Address (if different from above)                                         Phone Number
                                                                                  (          )
City                                                                                                       State  Zip

County

E-mail Address                                                                FEIN

                                                                              Registration Number          Period (MM/YY) - (MM/YY)

 Please Check One:          Political Subdivision             School District                                        —
Certification: I/we certify and declare that this application is true and correct and that it is made under penalty of perjury 
in the second degree.
Signature                                                                         Date (MM/DD/YY)

Title                                                                             Phone Number
                                                                                  (          )

                                                 Instructions
Complete form. Include documentation supporting proof of status as a government entity to enable timely processing of 
this application.

Mail completed form and documentation to:
      Colorado Department of Revenue
    Denver, CO  80261-0009

Qualified Applicants                                           Definitions
1. Political Subdivision — United States or its agencies,      Gasoline—Gasoline is defined by § 39-27-101(12) CRS  
   State of Colorado or its agencies, towns, cities, counties, as any flammable liquid used primarily as a fuel for the  
   city and county, and any other political subdivision.       propulsion of motor vehicles, motor boats or aircraft. Any 
   Additional information may be requested and must            product blended with gasoline shall be considered gasoline.  
   be provided as proof to support that an organization        Gasoline does not include any “special fuel” as defined in § 
   is a government entity, i.e. articles of incorporation,     39-27-101(8) and § 39-27-101(29) C.R.S.
   funding authority, or legal documents supporting 
                                                               Special Fuel — Special fuel is defined by § 39-27-101 (29) 
   they are a government entity.
                                                               C.R.S. as diesel fuel, kerosene, liquefied petroleum gases, 
                                                               and natural gas used for the generation of power to propel a 
2. School District —  Must be formed as a political            motor vehicle on the highways of this state. “Special fuel” does 
   subdivision of this state.                                  not include gasoline as defined in § 39-27-101 (12) C.R.S.