Dr 1689 - Renewal Application For Liquefied Petroleum Gas Or Natural Gas Decal -

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Departmental Use Only
DR 1689 Web (03/31/11)
COLORADO DEPARTMENT OF REVENUE
DENVER, CO 80261-0009
RENEWAL APPLICATION
FOR LIQUEFIED PETROLEUM GAS
OR NATURAL GAS DECAL
Photocopy For Your Records
Note: Changes in Ownership Require Application For New Account
FEIN or Social Security Number
Account Number
5560-750
Due Date
Period (MM/YY–MM/YY)
Failure to comply constitutes a violation and is subject to a penalty of misdemeanor. SEE INSTRUCTIONS ON REVERSE SIDE
A. Vehicles with a gross weight of 10,000 pounds or less
State
License Plate No.
Fee: $70.00 per vehicle
CO
CO
CO
CO
CO
TOTAL A. Fees paid and decals ordered. Enter total decals & amount
Total Fee
Total Decals (892)
•
•
(100)
00
$
B. Vehicles with a gross weight of 10,001–16,000 pounds
State
License Plate No.
Fee: $100.00 per vehicle
CO
CO
CO
Total Fee
TOTAL B. Fees paid and decals ordered. Enter total decals & amount
Total Decals (894)
•
•
$
(120)
00
C. Vehicles with a gross weight of more than 16,000 pounds
State
License Plate No.
Fee: $125.00 per vehicle
CO
CO
CO
TOTAL C. Fees paid and decals ordered. Enter total decals & amount
Total Fee
Total Decals (896)
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
(130)
returned. If your check is rejected due to insufficient or uncollected funds, the Department of Revenue
$
00
may collect the payment amount directly from your bank account electronically.
Amount Owed
If additional space is needed,
If you no longer own a LPG/NG vehicle, please mark
(355)
$
.00
please photocopy this form
this box in order that we may close your account.
(ADD TOTALS FROM A, B, & C)
Signature of Applicant
Attachment H

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