Form Dr 1689 - Renewal Application For Liquefied Petroleum Gas Or Natural Gas Decal

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DEPARTMENTAL USE ONLY
DR 1689 (08/10/05)
RENEWAL APPLICATION
COLORADO DEPARTMENT OF REVENUE
FOR LIQUEFIED PETROLEUM
DENVER CO 80261-0009
(303) 205-8205
GAS OR NATURAL GAS DECAL
MAKE A COPY FOR
NOTE: CHANGES IN OWNERSHIP REQUIRE APPLICATION FOR NEW ACCOUNT.
YOUR RECORDS
Account Number
F.E.I.N. or Social Security Number
MAKE
REMITTANCE
Due Date
Period (MM/YY-MM/YY)
5560-750
PAYABLE TO:
COLORADO
Failure to comply constitutes a violation and is subject to a penalty of misdemeanor.
DEPARTMENT
SEE INSTRUCTIONS ON REVERSE SIDE
OF REVENUE
A. VEHICLES WITH A GROSS WEIGHT OF 10,000 POUNDS OR LESS
State
License Plate No.
Fee - $70.00 per vehicle
CO
CO
CO
CO
CO
Total
TOTAL FEE
TOTAL A. FEES PAID AND DECALS ORDERED. ENTER TOTAL DECALS & AMOUNT
Decals (892)
I
$
I
(100)
l
B. VEHICLES WITH A GROSS WEIGHT OF 10,001 - 16,000 POUNDS
State
License Plate No.
Fee - $100.00 per vehicle
CO
CO
CO
Total
TOTAL FEE
TOTAL B. FEES PAID AND DECALS ORDERED. ENTER TOTAL DECALS & AMOUNT
Decals (894)
$
(120)
I
I
l
C. VEHICLES WITH A GROSS WEIGHT OF OVER 16,000 POUNDS
State
License Plate No.
Fee - $125.00 per vehicle
CO
CO
CO
Total
TOTAL FEE
TOTAL C. FEES PAID AND DECALS ORDERED. ENTER TOTAL DECALS & AMOUNT
Decals (896)
If your check is rejected due to insufficient or uncollected funds, the Department of Revenue may collect the
$
(130)
I
I
payment amount directly from your banking account electronically.
l
If you no longer own a LPG/NG vehicle, please
If additional space is
(ADD TOTALS
mark this box in order that we may close
needed, please photocopy
FROM
(355)
$
this form
your account.
A, B, & C)
l
Signature of Applicant
If your check is rejected due to isnufficient or uncollected
funds, the department of revenue may collect the paymet
amount directly from your banking account electronically.
Attachment H

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