Form Dr 0122 - International Fuel Tax Agreement Tax Report October 2006 (Page 2 of 2) in pdf

Form Dr 0122 - International Fuel Tax Agreement Tax Report October 2006 Page 2

10.

11.

12.

Juris-

Total

Taxable

Tax

Total

Tax

Net Taxable

Interest

Total

Miles

Gallons

Rate

(8 x 9)

diction

Taxable

Paid

Gallons

Due

(10 + 11)

(per gallon)

Miles

Gallons

(6-7)

Record the total for each column below

OTHER

Enter the total miles traveled in all jurisdictions that are not members of IFTA

13. Net Tax DUE (Total Column 10) Note: Enter total net tax amount on Line 13 or 14

(100)

MAKE CHECK PAYABLE

AND MAIL REPORT TO:

14. Net Tax CREDIT (Total Column 10)

(105)

Colorado Department of Revenue

15. PENALTY ($50.00 or 10% of Column 10, whichever is greater)

(200)

1375 Sherman St.

16. INTEREST (Total Column 11)

(300)

Denver, CO 80261-0016

17. Amount of TAX CREDIT to be refunded this period

(410)

(303) 205-8205

Photocopy and keep for

Paid via EFT

your own records.

18. TOTAL REMITTANCE (A separate check must accompany each return submitted)

(355)

•

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.

I certify under penalty of perjury in the second degree that to the best of my knowledge the above information is true and correct.

Signature

Date

Title

Telephone Number