Form Dr 0096 - Request For Tax Status Letter
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1DR 0096 (08/28/13)
*130096==19999*
COLORADO DEPARTMENT OF REVENUE
Business Tax Accounting, Room 208
PO Box 17087
Denver, CO 80217-0087
(303) 238-SERV (7378)
Request For Tax Status Letter
In accordance with the provision of § 38–25.5, C.R.S., I hereby request that the Department if Revenue issue a tax
status letter.
Last Name of Taxpayer/DBA
First Name of Taxpayer/DBA
Middle Initial
Address
City
State
Zip
Mailing Address
City
State
Zip
Colorado Account Number(s)
FEIN
Phone Number
(
)
Type of Taxes
List only taxes that are remitted to the Colorado Department of Revenue.*
Corporate Income
Consumer Use
SCFD Sales
County Sales
State Sales
State Withholding
Football Sales
Retailers Use
City Sales
RTD Sales
County Lodging
Severance
Department of Revenue
Make Check Payable To:
Fee: $7.00 Per Tax
To Be Paid Before Issuance of the Clearance
Total Remitted
Please make a copy for your records.
The state may convert your check to a one time electronic banking transaction. Your bank account may
be debited as early 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.
* Tax status letters are not available for individual income tax. Do Not send this form or payment as a request for an individual income
tax status letter.
If liability for any other tax exists and reports have not been filed, the tax may be assessed at any time. The issuance of this letter does
not fix, abate, modify, or cancel any liability or payment of money due or performance of an obligation to the State of Colorado.
I declare under the penalty of perjury in the second degree that I am a duly authorized officer of the corporation for which this tax status
letter is requested and that I am acting in my official capacity in making this request.
Authorization/Power of Attorney must be attached to this request if applicable.
Name
Title
Signature
Date
(MM/DD/YY)
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