Form Dr 1367 - Affidavit Of Sales Paid By Government Credit Card

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DR 1367 (05/04/12)
WEB
COLORADO DEPARTMENT OF REVENUE
AFFIDAVIT OF SALES PAID BY GOVERNMENT CREDIT CARD
I affirm that this purchase qualifies for the Colorado
I have checked the applicable boxes below regarding
sales tax exemption for sales to the United States
information about payment for this purchase.
government, the State of Colorado, its departments
I accept that I remain directly liable for the sales or use
and institutions, and its political subdivisions (county
tax assessment, and any applicable penalty or interest,
and local governments, school districts and special
if my purchase is found to not qualify for the exemption.
districts); is a government purchase used only in an
I understand that the vendor may request this affidavit
official governmental capacity; and will be paid directly
for every purchase.
by a government agency.
Please Print or Type
Customer Name
Driver’s License State and Last 4 Digits
Agency Name
Colorado Tax ID Number or FEIN
Customer Address
Agency Phone
City
State
ZIP Code
Check all that Apply
(For further information visit the Department of Revenue website at )
The agency exemption number is printed on the card. The number is 98 or 098-___________________________.
The card is a State/Central Travel Card. The State card has the State seal and the words”Tax Exempt” on it.
The card is a Purchasing Card. The federal version has a picture of the U.S. Capitol. The state card has “Commercial”
or “Purchasing” printed on it.
The card is a Fleet Card and has a picture of cars.
The card has an 8 digit exemption number below the cardholders name. The number is ______________________.
The card is an Integrated Card (w/picture of the U.S. flag) or a Travel Card (w/picture of an airplane) AND the sixth
digit of the card is 0,6,7,8 or 9.
The card is a Department of the Interior Mastercard issued by Bank of America w/acct beginning 5568-16.
The card is not Bureau of Land Management or National Park Service (Department of the Interior).
The card is State Department issued with the name/photo of the bearer and an image of an animal native to North
America on the card.
Signature of Customer
Date

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