Form Dr 0002 - Colorado Direct Pay Permit Application Page 2

*140002==29999*

See Next Page For Information Regarding Direct Payments of Sales Taxes

See Reverse Side For Requirements to Qualify For Direct Payment of Sales Taxes

Signature and Declaration:

An authorized employee, officer, partner, member or owner of the taxpayer identified above must sign and return this

form. Attach any appropriate power of attorney statement.

I understand and agree to the terms of this statement. I understand this agreement incorporates any statements made in

the application and attachments which limit the areas of use of this direct pay permit. I certify that the accounting system

and procedures in place will adequately identify, individually report and remit all state, district and local sales taxes owed.

Title

Printed Last Name

Printed First Name

Middle Initial Date

(MM/DD/YY)

Basis of Authority to Sign

Mail to and make checks payable to: Colorado Department of Revenue,

Denver, CO 80261-0013

Office Use Only

Approved By

Date

(MM/DD/YY)

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Parent category: Financial