Attachment A - Application For Approval Of Blackjack, Poker, Roulette, Craps, And Blackjack/poker Combination Variation Games - Colorado Division Of Gaming Page 5

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Colorado Division of Gaming
AUTHORIZATION FOR DISCLOSURE
FOR INTERNAL REVENUE SERVICE
Printed Full Legal Name (Last, First, Middle)
Social Security Number
Home Address (Street, City, State, Zip)
Name and Social Security Number of Person(s) With Whom You Have Filed A Joint Tax Return Within Past 5 Years
Type of Return
Form 1040, Individual Income Tax
Taxable Periods
Past Five (5) Years and Next Two (2) Years
I authorize the Internal Revenue Service to disclose tax return information (including, but not limited to, fact of filing, fact of
payment, and terms of installment agreement) regarding the above returns to the Division of Gaming, Colorado Dept of
Revenue.
Signature
Date
For Division of Gaming Use Only
Date:
Initials:
Fax Time:
Reply Received:
Mail In:
Attachment A
Page 5 of 5

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