Form Dr 8453 - Individual Income Tax Declaration For Electronic Filing

dr 8453 (09/27/10)

state of colorado

colorado department of revenue

denVer Co 80261-0005

individual income tax

declaration for electronic filing

do not mail this form to

the irs or the Colorado

department of reVenUe

retain with your records

dcn

taxpayer last name

first name

m.i.

social security number

spouse, if Joint return, last name

first name

m.i.

social security number

address

telephone number

(

)

City

state

Zip Code

part i — tax return information

(whole dollars only)

1. total income, line 22 from your federal form 1040, line 15 on form 1040a, or line 4 on form 1040eZ

2. taxable income, line 43 on federal form 1040, line 27 on form 1040a, or line 6 on form 1040eZ.

3. Colorado tax, line 15 on Colorado form 104

4. Colorado tax Withheld, line 21 on Colorado form 104

5. refund, line 44 Colorado form 104

6. amount You owe, line 48 on Colorado form 104

part ii — declaration of taxpayer

Under penalties of perjury, I declare that the information I have provided for electronic filing and the amounts shown in Part I above agree with the

amounts shown on my 2010 federal/Colorado income tax returns, and that said tax returns, statements, schedules and attachments are true, correct

and complete to the best of my knowledge and belief. I understand that I (or my Electronic Return Originator (ERO) if applicable) may be required to

provide paper copies of this declaration, my returns, withholding statements, schedules, and attachments upon request by the Colorado Department

of Revenue at any time during the period covered by the Colorado statute of limitations.

Your Signature

date

Spouse's Signature, if joint return both MUST sign date

part iii — declaration of ero/preparer/transmitter

if the transmitter did not prepare the tax return, check here

If I am not the preparer, I declare only that the amounts shown in Part I above agree with the amounts shown on the taxpayer's 2010 Federal/

Colorado income tax returns. if i am the preparer, under penalties of perjury i declare that i have reviewed the above taxpayer's 2010 federal/

Colorado income tax returns and that the information provided to me by the taxpayer and the amounts shown in Part I above agree with the

amounts shown on said tax returns, and that said tax returns, statements, schedules, and attachments are true, correct, and complete to the

best of my knowledge and belief. As preparer, I further declare that I have obtained the taxpayer's signature on this form at the time of filing

and have provided the taxpayer with copies of all forms and information filed. I also agree to maintain this signed Form (DR 8453) for the

period covered by the Colorado statute of limitations (VITA excluded. See page 2), and to provide paper copies of this declaration, said returns,

withholding statements, schedules and attachments upon request by the Colorado Department of Revenue at any time during this period.

ERO's Signature

Your social security number

or Preparer Identification Number

date

Check if also preparer

Form Dr 8453 - Individual Income Tax Declaration For Electronic Filing - 2010

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