Form Cr 0100ap - Colorado Sales Tax Withholding Account Application - 2014 Page 2

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If you acquired the business in whole or in part, complete the following:

8a. Prior Last Name or Business Name

First Name

Middle

8b.Date of Acquisition

(MM/DD/YY)

Initial

8c. Address

City

State

Zip

1. If seasonal, mark each business month:

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

2a. Filing Frequency: If sales tax is collected:

2b. First Day of Sales

(MM/DD/YY)

$15.00/ month or less — Annually

Under $300/ month — Quarterly

$300/ month or more — Monthly

Wholesale Only — Annually

Revenue Registration Account Number

(Dept. Use Only)

3. Indicate which applies to you:

Retail-Sales

Wholesaler

Charitable

Retailers-Use

(Withholding of $50,000 plus see Section D page 6) 2.

1. Filing frequency If wage withholding amount is W2

W2 Withholding

$1 – $6,999/Year — Quarterly

$7,000 – $49,999/ Year — Monthly

$50,000 +/ Year — Weekly

1099 Withholding

1a. Filing frequency If wage withholding amount is 1099

(Withholding of $50,000 plus see Section D page 6) 2a.

$1 – $6,999/Year — Quarterly

$7,000 – $49,999/ Year — Monthly

$50,000 +/ Year — Weekly

Oil/Gas Withholding

3a. First Day of Payroll, if applicable

3b. Payroll Records Phone Number

(MM/DD/YY)

(

)

Fees

Period Covered

(see fees on page 3)

From

MM/YY

(0020-810)

State Sales Tax Deposit

(355) $

0 0

MM/YY

12/

(0080-750)

Sales Tax License

(999) $

0 0

MM/YY

12/

(999) $

(0100-750)

Wholesale License

0 0

MM/YY

(1000-750)

Wage W2 Withholding

(999) $

0 0

MM/YY

(1020-750)

1099 Withholding

(999) $

0 0

MM/YY

12/

(0160-750)

Charitable License

(999) $

0 0

Mail to and Make Checks Payable to:

Colorado Department of Revenue,

PO Box 17087

Amount Owed $

.00

Denver, CO 80217-0087

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.

I declare under penalty of perjury in the second degree that the statements made in this application are

true and complete to the best of my knowledge.

Signature of Owner, Partner, or Corporate Officer Required

Title

Date

(MM/DD/YY)

(See fees and additional information on page 3)