Form Dr 0221 - Colorado Cigarette Tax Return
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2DR 0221 (08/09/07)
8A
Departmental Use Only
COLORADO CIGARETTE
COLORADO DEPT OF REVENUE
1375 SHERMAN ST
TAX RETURN
DENVER CO 80261-0003
(303) 205-8211 EXT. 6848
EFT Payment is Required.
Show change of ownership,
name and/or address here.
USE ACCOUNT NUMBER
LIABILITY INFORMATION
DUE DATE
PERIOD COVERED
for all reference
County
City
Industry
Type
Liability Date Act
Month
Day
Year
Year
Month
FEIN
If Federal Employers Identification Number (FEIN) is pre-printed in the above space, please check your records to see if you have the same number. If you
have a different number, correct the one above so that it corresponds with your records. If no number appears in the above space, please fill in with the FEIN
you have on your records.
0800-100
Gross Amount
Discount
Net Due
IMPORTANT: Failure to comply with the reporting and other requirements of Title
Column A
Column B
Column C
39, Session Laws of Colorado, is a violation subjecting the violator to the penalties
prescribed.
1. 20 Count Stamp Sheet Purchases (Stamp Type 121 Totals) .....................
2. 20 Count Stamp Roll Purchases (Stamp Type 122 Totals) ........................
3. 20 Count Wide Stamp Sheet Purchases (Stamp Type 126 Totals) ...........
4. 25 Count Stamp 10 Across Purchases (Stamp Type 123 Totals) ..............
5. 25 Count Stamp 12 Across Purchases (Stamp Type 124 Totals) ..............
(890)
(145)
6. Total purchases (Total each column on line 6) ...........................................
(200)
7. Late filing penalty:
A. 10% of line 6, column A ..............................................................................................................
(140)
B. Disallowed discount, line 6, column B ........................................................................................
(300)
8. Late filing interest:
PER MONTH .......................................................................................
9. Total of tax, penalty and interest (add lines 6, column C, 7A, 7B and 8).....................................................................................
(905)
10. Credit for returned stamps original manufacturer’s statement or
affidavit of returned merchandise must be attached. ...........................................................................
(900)
11. Discount taken on returned stamps (.9524% of line 10) ......................................................................
12. Net credit (line 10 minus line 11)................................................................................................................................................
13. If line 12 is more than line 9, subtract line 9 from line 12, this is your
(410)
overpayment (see instructions for how to apply for refund) ................................................................................................
$
(355)
14. If line 9 is more than line 12, subtract line 12 from line 9, this is the amount you owe (filing by EFT - put a zero in this box) ..
•
I hereby certify, under penalty of perjury in the second degree, that the statements made herein are, to the best of my knowledge, true and correct.
Name of Business or Taxpayer
Agent or Officer
Title
Date
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.
Please photocopy and retain copy for your records.
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