Form Dr 0021 - Colorado Severance Tax-Oil And Gas - 2012

Departmental Use Only

DR 0021 (09/12/12)

Web

COLORADO DEPARTMENT OF REVENUE

Denver, CO 80261-0007

COLORADO

(7001)

2012

Severance Tax–Oil and Gas

DR 0021

-or-

Fiscal Year Beginning

______________ , 2012

ending

______________ , 20___

Last Name (or Corporation Name)

First Name and Middle Initial

Deceased

Yourself

Social Security Number or Colorado Account Number

___/___/___

Your Spouse (see controlled group definition)

Spouse’s Social Security Number

___/___/___

Address

Federal Employer ID Number

City

State

ZIP Code

Telephone

(

)

•

If this is a final return check this box.....................................................................................

Are you a producer of Colorado Oil or Gas?

YES

NO

Round To The Nearest Dollar

Tax and Credit – Complete schedule DR 0021D first. Attach the DR 0021D to this form when you file.

•

1. Oil and gas tax, enter amount from line 5, DR 0021D

1

00

•

2. Impact assistance credit

2

00

3. Net tax, line 1 minus line 2 but not less than zero

3

00

Prepayments

•

4. Severance tax withheld, attach form DR 0021W

4

00

•

5. Estimated tax and extension payments

5

00

6. Total prepayments, add lines 4 and 5

6

00

Refund Or Balance Due

7. If line 6 is larger than line 3, enter your overpayment

7

00

•

8. Enter amount from line 7 you want refunded

8

00

•

9. Enter amount from line 7, if any, you want credited to estimated tax for next year

9

00

10. If line 3 is larger than line 6, enter the balance due here.

10

00

•

11. Interest on balance due

11

00

•

12. Penalty on balance due

12

00

•

13. Estimated tax penalty (corporations only)

13

00

•

14. Total amount due, add lines 10, 11, 12 and 13

Paid by EFT

14

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 Your Severance Tax Return Separately From Your Income Tax Return.

MAIL TO AND MAKE CHECKS PAYABLE TO: Colorado Department of Revenue

Denver, CO 80261-0007

Under penalty of perjury in the second degree, I declare that I have examined this return and to

Name, address and telephone number of

the best of my knowledge and belief it is true, correct, and complete.

person preparing return:

Signature of Individual Taxpayer

Date

Spouse’s Signature

Date

Signature of Corporate Officer

Date