*130075==19999*
DR 0075 (07/19/13)
colorado department of revenue
Denver, CO 80261-0005
Certification of
Qualified Enterprise Zone Contribution
This form must be completed and certified before claiming
Note- In order to claim an Enterprise Zone credit, you
must electronically file your income tax return and the EZ
the Colorado Enterprise Zone contribution income tax
credit. Submit a copy of this certified form with your
Carryforward Schedule (DR 1366). For an electronic filing
Colorado income tax return if your total contributions tax
hardship exception, call 303-238-7378.
credit for the year exceeds $250. Otherwise, retain a
Pursuant to §39-30-103.5(7), C.R.S., information on the
certified copy with your tax records. Tax credits are not
source and amount of enterprise zone contributions
available to contributors who receive a direct benefit from
may be disclosed as a public record.
the contribution. Taxpayers who make both cash and in-
kind contributions during the year should see FYI Income
23 for information on computing the credit.
To be completed by Certified Organization or Zone Administrator Receiving Contribution
First Name
Middle Initial
Last Name or Business Name
Address
City
State
Zip
SSN or Colorado Account Number
Phone Number
(
)
Name of Organization, Program or Project Receiving/Benefiting from Contribution
FEIN
Phone Number
(
)
1. Cash contributed to you for enterprise zone
Amount of
Date
Tax Credit
(MM/DD/YY)
project by person/organization above
Contribution
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
Item - Credit is 12.5% of the value of contribution
Date
Tax Credit
(MM/DD/YY)
Contribution
$
$
$
$
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)
1
2
