Form Dr 0020c - Colorado Coal Severance Tax Return - 2011 Page 2

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18. Impact assistance credit ..........................................................................................................

19. Net tax, line 17 minus line 18 but not less than zero ................................................................. 19

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20. Estimated tax and extension payments...................................................................................

21. If line 20 is larger than line 19, enter your overpayment ........................................................... 21

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22. Enter the amount from line 21, if any, you want refunded. Provide direct deposit information below ..

Checking

Routing number

Type:

Savings

Account number

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23. Enter amount from line 21, if any, you want credited to estimated tax for next year ................

24. If line 19 is larger than line 20, enter the balance of tax due ..................................................... 24

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25. Interest on balance of tax due .................................................................................................

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26. Penalty on balance of tax due .................................................................................................

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27. Estimated tax penalty due — see instructions ........................................................................

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28. Payment due with this return, add lines 24 thru 27 ......................................

Paid by EFT

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.

Under penalty of perjury in the second degree, I declare that I have examined this return and to the

Name, address and telephone number of

best of my knowledge and belief it is true, correct, and complete.

person preparing return:

Signature of Taxpayer or Corporate Officer

Date

MAIL TO AND MAKE CHECKS PAYABLE TO:

Colorado Department of Revenue

Denver, CO 80261-0007