Form Dr 0456 - Colorado Annual Reconciliation Of Severance Tax Withheld From Oil And Gas Payments

DR 0456 (02/20/08)

Departmental Use Only

COLORADO DEPARTMENT OF REVENUE

DENVER CO 80261-0007

COLORADO ANNUAL

RECONCILIATION OF SEVERANCE

TAX WITHHELD FROM OIL

AND GAS PAYMENTS

RETURN THIS COPY

Photocopy and keep copy for

your own records

ACCOUNT

PERIOD

DUE

FEIN

NUMBER

COVERED

DATE

(4000-130) Oil & Gas

1. Oil and gas severance taxes withheld during each quarter/month and remitted to the Colorado Department of Revenue

January ..............................................................................................................................................................................

$

00

•

February ............................................................................................................................................................................

$

00

•

March .................................................................................................................................................................................

$

00

•

April ....................................................................................................................................................................................

$

00

•

May ....................................................................................................................................................................................

$

00

•

June ...................................................................................................................................................................................

$

00

•

July ....................................................................................................................................................................................

$

00

•

August ................................................................................................................................................................................

$

00

•

September .........................................................................................................................................................................

$

00

•

October ..............................................................................................................................................................................

$

00

•

November ..........................................................................................................................................................................

$

00

•

December ..........................................................................................................................................................................

$

00

•

2. Total Colorado severance taxes withheld and remitted ....................................................................................................

$

00

•

3. Total Colorado severance taxes withheld per information reports (DR 21-W) ................................................................

$

00

•

Number of copies of form DR 21-W prepared ___________________

4. A. Additional severance withholding tax due (line 3 minus line 2) ........................................................................... (100)

00

•

or

B. Refund (line 2 minus line 3) .................................................................................................................................. (415)

00

•

5. Penalty

% ........................................................................................................................................ (200)

00

•

6. Interest (

% per month) ...................................................................................................................... (300)

00

•

$

00

Total Amount Due with this report .................................................................................................................................. (355)

●

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.

INSTRUCTIONS

This reconciliation must be filed with the Colorado Department of Revenue on or before April 15, following the close of the calendar

year. The Oil and Gas withholding Statement (form DR 21-W) for each person from whom Colorado gross severance tax was withheld from oil and

gas payments during the calendar year shall be retained in the records of every producer or purchaser for a period of three years and shall be made

available to the Department of Revenue upon the written request of the Department.

THIS FORM IS A RECONCILIATION FORM AND IS NOT TO BE USED AS A MONTHLY REPORT

Mail reconciliation to the Colorado Department of Revenue, Severance Tax Section, Denver Colorado 80261-0007.

I certify under penalty of perjury in the second degree that to the best of my knowlege the above information is true and correct.

Name of Business or Taxpayer

Date

Signature

Title