Form 104 - Colorado Individual Income Tax Form 2014 Page 3
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1
2
3*140104==39999*
Name
Account Number
45. Military Family Relief Fund
45
0 0
46. Colorado Cancer Fund
46
0 0
47. Make-A-Wish Foundation of Colorado Fund
47
0 0
48. Unwanted Horse Fund
48
0 0
49. Colorado Multiple Sclerosis Fund
49
0 0
50. Public Education Fund
50
0 0
51. Round Up River Ranch Fund
51
0 0
52. 9Health Fair Fund
52
0 0
53. Subtotal, add lines 37 through 52
53
0 0
54. Refund, subtract line 53 from line 36 (see page 11)
54
0 0
Direct
Type:
Checking
Routing Number
Savings
CollegeInvest 529
Deposit
Account Number
For questions regarding CollegeInvest direct deposit or to open an account call 800-448-2424 or visit
Amount You Owe
55. Net Tax Due, subtract line 34 from line 26 (include the subtotal from line 53)
55
0 0
56. Delinquent Payment Penalty (see instructions)
56
0 0
57. Delinquent Payment Interest (see instructions)
57
0 0
58. Estimated Tax Penalty (see instructions)
58
0 0
59. Amount You Owe, add lines 55, 56, 57 and 58
59
0 0
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.
Third Party Designee
Do you want to allow another person to discuss this
return and any other information related to this return
No
Yes. Complete the following:
with the Colorado Department of Revenue?
Designee’s Name
Phone Number
(
)
Sign Below
Under penalties of perjury, I declare that to the best of my knowledge and belief, this return is true, correct, and complete.
Your Signature
Date
(MM/DD/YY)
Spouse Signature. If joint return, BOTH must sign.
Date
(MM/DD/YY)
Paid Preparer’s Name
Paid Preparer’s Phone
(
)
Paid Preparer’s Address
City
State
Zip
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