Form Dr 1089 - Colorado Tax Amnesty Application And Request For Agreement To Pay Installment Plan - 2003
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2DR 1089 (04/03)
COLORADO DEPARTMENT OF REVENUE
COLORADO TAX AMNESTY
P.O. BOX 17087
DENVER CO 80217-0087
COLORADO TAX AMNESTY APPLICATION
AND REQUEST FOR AGREEMENT
TO PAY INSTALLMENT PLAN
A. TAXPAYER INFORMATION
DO NOT WRITE IN THIS AREA
For Individual Income Tax
Taxpayer Name (last, first, middle initial)
Social Security Number
Spouse’s Name if combined amnesty (last, first, middle initial)
Social Security Number
Address
City
State
ZIP
For Business Taxes
Business Name (DBA)
Colorado Tax ID Number
Owner Name
FEIN
Business Address
City
State
ZIP
Contact Information
Daytime Phone Number
Fax Number
Evening Phone Number
(
)
(
)
(
)
B. TAXES ELIGIBLE FOR TAX AMNESTY
The following taxes are eligible for tax amnesty. You must submit a separate Tax Amnesty Application, tax return and check for each type
of tax for which you are requesting tax amnesty. Please indicate below the type of tax this application is for:
CHECK ONE BOX ONLY!
Gasoline and Special Fuel taxes
RTD sales and use taxes
Colorado individual or corporate income tax
Cigarette and tobacco product taxes
Scientific and Cultural Facilities District
State sales and use taxes
Severance tax
sales and use taxes
State-collected local sales and use taxes (for
Waste tire fees
Metropolitan Football Stadium District sales
a complete list of state-collected local sales
Local Marketing and Promotion taxes
and use taxes
and use taxes, see Department of Revenue
County lodging tax
Denver Metropolitan Major Baseball
Publication 1002, at
County rental tax
Stadium District sales and use taxes
under (“Forms”)
Local Improvement District taxes
Rural Transportation Authority sales and
Estate, Inheritance and Gift tax
use taxes
Blank tax forms can be obtained at
IMPORTANT
- Many credits from prior years are no longer available. These unavailable credits include the Sales Tax Refund (TABOR) credit.
C. TAX PERIODS
The taxes eligible for amnesty are for tax periods that ended on or before December 31, 2002, including returns for which the Department
has granted an extension beyond this date.
D. DECLARATION
Please remember to: Sign the amnesty application and tax return(s) and write your Social
Security Number and/or Business Tax Number and “Tax Amnesty” on your check (do not send cash).
/ SIGNATURE
Under penalties of perjury, I declare that I have examined this form, including any accompanying returns and schedules and to the
best of my knowledge and belief they are true, correct and complete. I agree to satisfy all of the requirements for amnesty, and I
understand that if all requirements are not satisfied, my request for amnesty will be denied and approval will be deemed revoked. I
understand that my payment of taxes pursuant to this amnesty program constitutes a waiver of any right to file a claim for refund or
an amended return for refund, or seek an administrative review, administrative hearing, or district court appeal pursuant to 39-21-103,
39-21-104, and 39-21-105 CRS. I further declare that I understand that all information obtained pursuant to this amnesty program
may be disclosed to the Federal Internal Revenue Service.
Signature of Taxpayer or authorized official
Printed Name
Title (if applicable)
Signature of Spouse (if joint return)
Date
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