Form 104 - Colorado Individual Income Tax - 2015 Page 5

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*150104V259999*
FORM 104 (11/16/15)
COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0005
Name
Account Number
66. Refund, subtract line 65 from line 48 (see instructions)
66
0 0
Direct
Type:
Checking
Routing Number
Savings
CollegeInvest 529
Deposit
Account Number
For questions regarding CollegeInvest direct deposit or to open an account call 800-448-2424 or visit
Amount You Owe
67. Net Tax Due, subtract line 47 from line 37 (include the subtotal from line 65)
67
0 0
68. Delinquent Payment Penalty (see instructions)
68
0 0
69. Delinquent Payment Interest (see instructions)
69
0 0
70. Estimated Tax Penalty (see instructions)
70
0 0
71. Amount You Owe, add lines 67, 68, 69 and 70
71
0 0
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.
Third Party Designee
Do you want to allow another person to discuss this
return and any other information related to this return
No
Yes. Complete the following:
with the Colorado Department of Revenue?
Designee’s Name
Phone Number
(
)
Under penalties of perjury, I declare that to the best of my knowledge and belief, this return is true, correct, and complete.
Sign Below
Your Signature
Date
(MM/DD/YY)
Spouse Signature. If joint return, BOTH must sign.
Date
(MM/DD/YY)
Paid Preparer’s Name
Paid Preparer’s Phone
(
)
Paid Preparer’s Address
City
State
Zip

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