Form Dr 0002 - Colorado Direct Pay Permit Application - 2000

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DR 0002 (01/00)
19
1375 Sherman Street
Denver CO 80261-0013
COLORADO DIRECT PAY PERMIT APPLICATION
1. REASON FOR FILING THIS APPLICATION
Original Application
Renewal
2. INDICATE TYPE OF ORGANIZATION
Individual
Non-profit 501 (C)(3)
Corporation
'S' Corporation
(Please enclose copy of the IRS
General Partnership
letter of exemption.)
Limited Partnership
Association
Estate
Other Non-Profit
Limited Liability Company (LLC)
Government
Limited Liability Partnership (LLP)
Joint Venture
Limited Liability Limited
Other_____________________
DO NOT WRITE IN THIS SPACE
Partnership (LLLP)
Trust
1. Taxpayer Name (owner, partners or corporate name) (last, first, middle) Permit #
Period
0085-750 (999) 0.00
L90-
2a. Trade Name/Doing Business As (if applicable)
2b. Federal Employer Identification Number (FEIN)
DP
3a. Street Address of Principal Place of Business in Colorado
City
State
ZIP
3b. County
If business is within limits of a city, what city? Telephone
(
)
4a. In Care Of (c/o)
4b. Mailing Address (if different from above) (include unit #)
City
State
ZIP
Telephone
(
)
5. What products and/or services do you provide?
6a. Owner/Partner/Corp. Officer
Title
Social Security #
Federal Employer Identification Number (FEIN)
6b. Address (residence or P.O. Box, street, city, state, ZIP)
Telephone
(
)
7a. Owner/Partner/Corp. Officer
Title
Social Security #
Federal Employer Identification Number (FEIN)
7b. Address (residence or P.O. Box, street, city, state, ZIP)
Telephone
(
)
8. Enter the aggregate amount of Colorado purchases, which were made in the previous 12 months, subject to the tax imposed by Article 26
of Title 39 C.R.S. $ _________________ .
SEE REVERSE SIDE FOR INFORMATION REGARDING DIRECT PAYMENT OF SALES TAXES
SEE REVERSE SIDE FOR REQUIREMENT TO QUALIFY FOR DIRECT PAYMENT OF SALES TAXES
SIGNATURE AND DECLARATION:
An authorized employee, officer, partner, member or owner of the taxpayer identified above must sign and return this form. Attach
any appropriate power of attorney statement.
I understand and agree to the terms of this statement. I understand this agreement incorporates any statements made in the
application and attachments which limit the areas of use of this direct pay permit. I certify that the accounting system and
procedures in place will adequately identify, individually report and remit all state, district and local sales taxes owed.
By
Title
Typed Name
Date
Basis of Authority to Sign
Mail To:
COLORADO DEPARTMENT OF REVENUE
DENVER, COLORADO 80261
OFFICE USE ONLY
Approved by __________________________________ Date __________

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