Form 104 - Colorado Individual Income Tax Return

Page 14

25 Enter the amount from federal Form 1040, line 37; or from federal Form 1040A, line 21; or from

.00

federal Form 1040EZ, line 4 (Federal Adjusted Gross Income) .............................................. 25

.00

26 If line 24 is more than line 20, subtract line 20 from line 24. This is your overpayment ............ 26

.00

27 Amount you want credited to your 2010 estimated tax............................................................ 27

ENTER THE AMOUNT, IF ANY, YOU WISH TO CONTRIbUTE TO:

.00

28 The Nongame and Endangered Wildlife Cash Fund ............................................................... 28

.00

29 The Colorado Domestic Abuse Program Fund ........................................................................ 29

.00

30 The Homeless Prevention Activities Program Fund ................................................................ 30

.00

31 The Special Olympics Colorado Fund ..................................................................................... 31

.00

32 The Western Slope Military Veterans’ Cemetery Fund ............................................................ 32

.00

33 The Pet Overpopulation Fund ................................................................................................ 33

.00

34 The Colorado Healthy Rivers Fund ......................................................................................... 34

.00

35 The Alzheimer’s Association Fund .......................................................................................... 35

.00

36 The Military Family Relief Fund ............................................................................................... 36

.00

37 The Multiple Sclerosis Fund .................................................................................................... 37

.00

38 The Colorado breast and Women’s Reproductive Cancers Fund ........................................... 38

.00

39 The Adult Stem Cell Cure Fund ............................................................................................... 39

.00

40 The 9Health Fair Fund............................................................................................................. 40

.00

41 The Make-A-Wish Foundation of Colorado Fund .................................................................... 41

.00

42 Total of lines 27 through 41 ....................................................................................................... 42

.00

43 line 26 minus line 42. This is your REFUND. e-file this return. Get your refund faster! ....... 43

(See page 9)

Type:

Checking

Savings

Routing number

Account number

AMOUNT YOU OWE

44 Penalty, also include on line 47 if applicable ........................................................................... 44

.00

45 Interest, also include on line 47 if applicable ........................................................................... 45

.00

46 Estimated tax penalty, also include on line 47 if applicable ..................................................... 46

.00

47 If line 20 is more than line 24, subtract line 24 from line 20. This is the amount you owe.

.00

Include amounts entered on lines 27 through 41, if any .......................................................... 47

• Pay online at , or make check payable to Colorado Department of Revenue.

• To ensure you receive credit for your payment by check, write your social security number and “Form 104” on your check.

• DO NOT send cash; DO NOT staple check to return.

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.

Under penalties of perjury, I declare that to the best of my knowledge and belief, this return is true, correct, and complete.

Your Signature

Spouse’s Signature. If joint return, bOTH must sign.

Date

Year of birth

Date

Year of birth

MAIL YOUR RETURN TO:

Paid Preparer’s Name, Address and Telephone Number

COlORADO DEPARTMENT OF REVENUE

DENVER, CO 80261-0005

(10/14/09)