Form Dr 0075 - Certification Of Qualified Enterprise Zone Contribution
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2*140075==19999*
DR 0075 (10/14/14)
COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0005
Certification of Qualified Enterprise Zone Contribution
To be completed by Certified Organization or Zone Administrator Receiving Contribution
Donor Last Name or Business Name
First Name
Middle Initial
Address
City
State
Zip
Colorado Account Number or Last 4 Digits of SSN
Phone Number
(
)
Name of Organization, Program or Project Receiving/Benefiting from Contribution
FEIN
Phone Number
(
)
Amount of
1. Cash contributed to you for enterprise zone
Date
Tax Credit
Contribution
(MM/DD/YY)
project by person/organization above
Credit is 25% of the amount of contribution
$
$
2. In-kind contributions: Description of, and your valuation of, non-monetary contributions to you by person/organization
above. Credit for in-kind contributions alone is one-half of percentage allowed for cash contributions. Attach additional
sheet if necessary.
Value of
Date
Tax Credit
Item - Credit is 12.5% of the value of contribution
Contribution
(MM/DD/YY)
$
$
$
$
3. Zone administrator-approved use to which contribution has been/will be put. Be specific.
Certification of Receipt of Qualified Contribution
I, duly authorized Enterprise Zone Administrator or official of this certified Enterprise Zone organization, hereby certify
the receipt of, and the value and use of these contributors.
Signature of Enterprise Zone Administrator or Authorized Official of Qualified Organization
Title
Date
(MM/DD/YY)
Certification of Organization/Project — to be completed by Enterprise Zone Administrator
I, duly authorized Enterprise Zone Administrator or official of this certified Enterprise Zone organization, hereby certify
the receipt of, and the value and use of these contributors.
Name of Benefiting Organization, Program or Project
Date this project first approved by zone
Certification Period
(MM/DD/YY)
(MM/YY-MM/YY)
–
Address
City
State
Zip
To be signed if this form certifies an organization to receive direct contributions; leave blank if contribution is to
you as zone administrator.
I, duly authorized enterprise zone administrator, hereby certify that the above named organization, program or project
has been certified to receive direct contributions on behalf of the specified enterprise zone purpose. I further certify that
the organization, program or project has been accepted by the state Economic Development Commission.
Signature of Enterprise Zone Administrator
Enterprise Zone
Date
Fee
(MM/DD/YY)
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