Form Dr 8453 - Individual Income Tax Declaration For Electronic Filing
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2DR 8453 (11/30/11)
STATE OF COLORADO
COLORADO DEPARTMENT OF REVENUE
DENVER CO 80261-0005
INDIVIDUAL INCOME TAX
DECLARATION FOR ELECTRONIC FILING
DO NOT MAIL THIS FORM TO
THE IRS OR THE COLORADO DEPARTMENT OF REVENUE
RETAIN WITH YOUR RECORDS
DCN
Taxpayer Last Name
First Name
M.I.
Social Security Number
Spouse, If Joint Return, Last Name
First Name
M.I.
Social Security Number
Address
Telephone Number
(
)
City
State
ZIP
Part I — TAX RETURN INFORMATION
1. Total Income, line 22 from your federal form 1040, line 15 on form 1040A, or line 4 on form 1040EZ .................1.
2. Taxable Income, line 43 on federal form 1040, line 27 on form 1040A, line 6 on form 1040EZ
2.
...............................
3. Colorado Tax, line 15 on Colorado form 104 ......................................................................................................... 3.
4. Colorado Tax Withheld, line 21 on Colorado form 104 .......................................................................................... 4.
5. Refund, line 44 Colorado form 104 ....................................................................................................................... 5.
6. Amount You Owe, line 49 on Colorado form 104 ..................................................................................................6.
Part II — DECLARATION OF TAXPAYER
Under penalties of perjury, I declare that the information I have provided for electronic filing and the amounts shown in Part I above agree with
the amounts shown on my 2011 Federal/Colorado income tax returns, and that said tax returns, statements, schedules and attachments are true,
correct, and complete to the best of my knowledge and belief. I understand that I (or my Electronic Return Originator (ERO) if applicable) may be
required to provide paper copies of this declaration, my returns, withholding statements, schedules, and attachments upon request by the Colorado
Department of Revenue at any time during the period covered by the Colorado statute of limitations.
Your Signature
Date
Spouse's Signature, if joint return both MUST sign
Date
Part III — DECLARATION OF ERO/PREPARER/TRANSMITTER
(If the transmitter did not prepare the tax return, check here
)
If I am not the preparer, I declare only that the amounts shown in Part I above agree with the amounts shown on the taxpayer's 2011
Federal/Colorado income tax returns. If I am the preparer, under penalties of perjury I declare that I have reviewed the above taxpayer's
2011 Federal/Colorado income tax returns and that the information provided to me by the taxpayer and the amounts shown in Part I above
agree with the amounts shown on said tax returns, and that said tax returns, statements, schedules, and attachments are true, correct,
and complete to the best of my knowledge and belief. As preparer, I further declare that I have obtained the taxpayer's signature on this
form at the time of filing and have provided the taxpayer with copies of all forms and information filed. I also agree to maintain this signed
Form (DR 8453) for the period covered by the Colorado statute of limitations, and to provide paper copies of this declaration, said returns,
withholding statements, schedules and attachments upon request by the Colorado Department of Revenue at any time during this period.
ERO's Signature
Your Social Security Number
or Preparer Identification Number
Check if also preparer
Date
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