DR 0900 (09/10/15)
*150900==19999*
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261-0008
(0011)
2015 Individual Income Tax Payment Form
(Calendar year — Due April 18, 2016)
Caution!
This form MUST accompany your payment if you filed electronically and wish to pay by check.
The Department strongly recommends that you file using
Complete the form below. The amount on the check and
Revenue Online or other electronic method and remit your
the amount entered on the payment form must be the
payment electronically or by EFT.
same. This will help maintain accuracy in your tax account.
Be sure to keep a copy of the money order or note the
However, to pay by mail, make check or money order
check number with your tax records.
payable to the Colorado Department of Revenue. Be sure
to round your payment to the nearest dollar. Clearly write
DO NOT submit a paper return if you have already filed
your Social Security number and “2015 Form 104” on the
electronically.
check memo line.
Return this form with check or money order payable to the Colorado Department of Revenue, Denver, Colorado 80261-0008. Write your
Social Security number and “2015 Form 104” on your check or money order. Do not send cash. Enclose, but do not staple or attach, your
payment with this form.
First Name
Middle Initial SSN
Your Last Name
Spouse Last Name (if joint)
Spouse First Name
Middle Initial Spouse SSN
Address
City
ZIP
State
IF NO PAYMENT IS DUE, DO NOT FILE THIS FORM.
Amount of Payment
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.
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