Form Dr 0077 - Certification Of Qualified Enterprise Zone Research & Development Expenditures Page 2

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Certification

This form certifies that your facility is located within the

Businesses: Read FYI Publication - Income 22 and

boundaries of a Colorado Enterprise Zone, and collects

calculate your Colorado Enterprise Zone credit using

information required by §39-30-103(4), C.R.S. Use this

form 112CR. Complete the following information and

form only if you are unable to complete the certification

forward the signed form to the appropriate Enterprise

process online at

Zone Administrator. Include a stamped, self-addressed

envelope if you mail the form to the Administrator.

Check here if a certification has been filed for this facility in a prior year:

Research and development expenditures in zone during year

Amount of EZ research and development tax credit claimed

Taxpayer Signature

I declare that all of the above information is true and correct to the best of my knowledge and belief.

Signature of Authorized Company Official/Owner

SSN or FEIN

Colorado Account Number (CAN)

Print Name

Title

Date

(MM/DD/YY)

Tax Preparer or other contact for follow up information (please print)

Phone Number

(

)

Zone Administrator: Verify the location of the facility, then sign and date where indicated. Return the certified form

to the business.

Certification By Zone Administrator

I, the duly authorized administrator of the above-mentioned Enterprise Zone, hereby certify to the State of Colorado,

Department of Revenue that the above named facility is entirely within the designated Enterprise Zone.

Effective Date of Zone for this Location

Signature of Zone Administrator

Date

(MM/DD/YY)

Submit a copy of the certified form with your income tax return.

For tax years 2012 and thereafter, you must file electronically when claiming any Enterprise Zone credit.

For more information, contact:

• Colorado Department of Revenue, Denver, CO 80261-0005. Phone: (303) 238-SERV (7378).

See Department of Revenue "FYI" Publications for additional information:

• Colorado Office of Economic Development and International Trade, 1625 Broadway, Suite 2700, Denver, CO 80202.

Phone: (303) 892-3840.

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