Form Dr 0023 - Request For Severance Withholding Waiver printable pdf download

Form Dr 0023 - Request For Severance Withholding Waiver

DR 0023 (09/22/10)

Departmental Use Only

Colorado department of revenue

1375 SheRman St

DenveR CO 80261

request for

severance Withholding Waiver

name of Company

mailing address

City

State

ZIP

the above company requests a waiver of the Colorado severance withholding requirement for oil and/or gas

produced by the wells described below. Further, the company certifies that all wells described below produce fifteen

(15) barrels, or less, of oil or 90,000 cubic feet, or less, of gas per day for the average of all producing days during

the taxable year, as evidenced by records and reports that are open to inspection by the Colorado Department of

Revenue. the company also understands that the approval of the waiver is subject to audit.

(If you need more space,

Wells for WhiCh Waiver of severanCe Withholding requirement is requested:

attach additional pages.)

Well name

american petroleum industry (api) number

Please complete and sign the form and return it to the address or fax number above. Upon approval, a waiver letter will be mailed to you.

under penalty of perjury in the second degree, i declare that to the best of my knowledge and belief this request is true,

correct and complete.

Signature

Date

DOR approval

title

Date

Form Dr 0023 - Request For Severance Withholding Waiver