Form Dr 0526 - Prepaid Wireless Surcharge Return (Page 3 of 3) in pdf

Departmental Use Only

DR 0526 (08/25/16)

COLORADO DEPARTMENT OF REVENUE

Denver, CO 80261-0009

Prepaid Wireless Surcharge Return

*160526==19999*

Mail to: Colorado Department of Revenue, Denver, CO 80261-0009

Make checks or money orders payable to: Colorado Department of Revenue.

Write your account number on your check and make a copy of the return for your records.

Account Number

FEIN

SSN

Period

(MM/YY-MM/YY)

–

Business Name or Taxpayer Last Name

First Name

Due Date

(MM/DD/YY)

Address

City

State

Zip

0526-105

Check if amended return

E911 Surcharge

TRS Surcharge

1. Sales of prepaid wireless telecommunications sold,

including federal subsidies.

1 $

0 0 $

0 0

2. Sales of prepaid wireless telecommunication

service to other licensed dealers for resale

2 $

0 0 $

0 0

3. Imputed value of federally supported lifeline

services reported on line 1

0 0

4. Total prepaid wireless telecommunication service

0 0 $

0 0

not subject to the surcharge (add lines 2 and 3)

4 $

5. Net prepaid wireless telecommunication

service subject to the surcharge

(subtract line 4 from line 1)

5 $

0 0 $

0 0

6. E911 surcharge and TRS surcharge rates

0.014

0.001

7. Total E911 and TRS surcharge collected

7 $

0 0 $

0 0

(multiply line 5 by rate on line 6)

0 0 $

0 0

8. Service fee (multiply line 7 by 3.3% (.033))

8 $

9. Net E911 and TRS surcharge due (subtract line 8

9 $

0 0 $

0 0

from line 7)

10. Total surcharge due (add both columns of lines 9)

10 $

0 0

11. Penalty (multiply line 10 by 10% (0.1))

11 $

Interest Rate

12. Interest (multiply line 10 by

0.0025

12 $

0 0

13. Total Remitted (add lines 10, 11, and 12)

Paid by EFT

.00

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.

Signed under penalty of perjury in the second degree.

Signature

Date

Phone Number

(MM/DD/YY)

(

)