Form 112x - Amended C Corporation Income Tax Return - 2015 Page 5

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*150112X=49999*
Direct
Type:
Checking
Savings
Routing Number
Deposit
Account Number
Pay electronically at or mail and make checks payable to:
Colorado Department of Revenue, Denver, CO 80261-0006
Under penalties of perjury in the second degree, I declare that I have examined this return and to the best of my
knowledge is true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of
which preparer has any knowledge.
Signature of Officer
Title of Officer
Date
(MM/DD/YY)
Paid Preparer’s Last Name
First Name
Middle Initial
Paid Preparer’s Address
Phone Number
(
)
City
State
ZIP

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