Form Dr 0021 - Colorado Severance Tax - Oil And Gas

Form Dr 0021 - Colorado Severance Tax - Oil And Gas - 2013 Page 2

*130021==29999*

Balance Due

10. If line 3 is larger than line 6, enter the balance due here

•

11. Interest on balance due

•

12. Penalty on balance due

•

13. Estimated tax penalty (corporations only)

•

14. Total amount due, add lines 10, 11, 12 and 13

Paid by EFT

1 4

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.

Mail Your Severance Tax Return Separately From Your Income Tax Return.

Attach Form DR 0021W Withholding Forms.

MAIL TO AND MAKE CHECKS PAYABLE TO: Colorado Department of Revenue

Denver, CO 80261-0006

Under penalty of perjury in the second degree, I declare that I have examined this return and to the best of my

knowledge and belief it is true, correct, and complete.

Signature of Individual Taxpayer

Date

(MM/DD/YY)

Spouse’s Signature

Date

(MM/DD/YY)

Signature of Corporate Officer

Date

(MM/DD/YY)

Preparer’s Last Name

Preparer’s First Name

Preparer’s Telephone Number

Address

City

State

Zip

Form Dr 0021 - Colorado Severance Tax - Oil And Gas - 2013 Page 2