Dr 0138 11/13/03 - Refund Inquiry - Colorado Department Of Revenue
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1DR 0138 (11/13/03)
COLORADO DEPARTMENT OF REVENUE
DENVER, COLORADO 80261-0005
REFUND INQUIRY
DATE:
SPOUSE'S NAME:
LAST
FIRST
INITIAL
PRINT
NAME
CURRENT ADDRESS (STREET AND NUMBER)
SPOUSE'S SSN
YOUR SOCIAL SECURITY NO.
CITY
STATE
ZIP
PHONE NUMBER
YEAR:
NEW ADDRESS?
FILED
ORIGINAL
AMENDED
YES
NO
1.
Your overpayment was credited to_____________________________________________. If you wish this
refunded, please sign the following statement and return a copy of this form.
I (we) would like my (our) overpayment refunded to me (us).
Signature of Taxpayer
Signature of Taxpayer's Spouse (if joint or combined return filed)
2.
Your refund has been issued, however it has not been cashed. In order for us to issue you another refund, we
must have your permission to cancel the warrant issued. Please sign the following statement and you must
return the WHITE copy of this form.
I (we) hereby certify under penalty of perjury in the second degree, that original Warrant No. __________________ ,
issued to me (us) on ________________ in the amount of $_ _________________ _ has not been received, is lost,
or has been stolen. In the event that it shall be found, I (we)understand it will not be negotiated and will
promptly return it to the Colorado Department of Revenue.
Type:
Savings
Checking
Routing number
See reverse side of form for
Account number
Direct Deposit instructions
Signature of Taxpayer
Signature of Taxpayer's Spouse (if joint or combined return filed)
3.
Your refund for $ _______________________________ was issued on Warrant No. __________________ ,
Bank Sequence Number, ________________________ Validation Number _________________________ ,
on _________________________ and cleared our bank ____________________ .You may order a copy of
the cancelled check from the Colorado Department of Revenue, Denver, CO 80261-0005. Any warrant cashed
prior to 1998 is no longer available through Tax Files. It must instead be ordered from State Archives at 1313
Sherman St. IB20, Denver, CO 80203 at a cost of $15.00. ($25.00 if mailed outside of Colorado)
FOR OFFICE USE ONLY: Photo Copy Ordered by
Voucher Number
Completed by:
Approved by:
Outstanding Date
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