Form Dr 0084 - Substitute Colorado W-2 Form
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1*130084==19999*
DR 0084 (08/30/13)
COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0005
Substitute Colorado W-2 Form
See Form Below
Photocopy for your records.
DR 0084 (08/30/13)
Employer’s name, address and ZIP Code:
State of Colorado
Department of Revenue
SUBSTITUTE COLORADO W-2 FORM
Denver, CO 80261-0005
FOR INCOME TAX WITHHELD
Employer’s Colorado Identification No.
Federal Employer’s Identification No.
●
Employee’s Social Security No.
DATES OF EMPLOYMENT
FROM
TO
Employee’s name (first, middle, last):
Year (
Month
Year
Month
(YYYY)
(MM)
YYYY)
(MM)
FEDERAL INCOME TAX WITH-
COLO. INCOME TAX
TOTAL WAGES
Employee’s address and ZIP Code:
(before payroll deductions)
WITHHELD, if any
HELD, if any
●
NOTE: If taxpayer was employed by more than one employer, a separate statement covering each employment and the amount of tax withheld must be filed.
How did you determine the amounts listed above?
Give reason why Form W-2, or the Statement of Corrected Income and Tax Amounts was not furnished by your employer (or the payer), if
known. Explain your efforts to obtain the required information.
I declare, under penalty of perjury in the second degree, that the statements made herein are true to the best of my knowledge and belief.
Signature:
Date:
(MM/DD/YY)
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