Form Dr 0221 - Colorado Cigarette Tax Return
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1
2Department Use Only
DR 0221 (01/20/12)
COLORADO DEPARTMENT OF REVENUE
COLORADO CIGARETTE
1375 SHERMAN STREET
DENVER CO 80261-0009
TAX RETURN
Check here if this is an amended return
ACCOUNT NUMBER
NAME
PERIOD
DUE DATE
Month
Year
Month
Day
Year
IMPORTANT: Failure to comply with the reporting and other requirements of Title 39, Session Laws of Colorado, is a violation
subjecting the violator to the penalties prescribed.
0221-100
$
00
1. 20 Count Stamp Sheet Purchases (stamp type 121 totals) .. ...............................................................
$
00
2. 20 Count Stamp Roll Purchases (stamp type 122 totals) ....................................................................
$
00
3. 20 Count Wide Stamp Sheet Purchases (stamp type 126 totals) .........................................................
$
00
4. 25 Count Stamp 10 Across Purchases (stamp type 123 totals) ............................................................
$
00
5. 25 Count Stamp 12 Across Purchases (stamp type 124 totals) ............................................................
$
00
6
6. Total purchases (add lines 1 through 5) ..........................................................................................
$
00
7. Service fee allowed vendor (only if paid by EFT on or before due date) ..............................................
$
00
8. Net Stamp Purchases due (subtract line 7 from line 6).........................................................................
$
00
9
9. Sample and test panel packs (Manufacturers Only) ....................................................................
$
00
10. Total tax due (add lines 8 and 9) ..................................................................................... ......................
11. Credit for returned stamps. Original manufacturer’s statement or affidavit of returned
$
00
merchandise must be attached ...................................................................................................... 11
$
00
12. Discount taken on returned stamps (.9524% of line 11) ................................................. ......................
$
00
13. Net credit (line 11 minus line 12) ..................................................................................... ......................
$
00
14. Net tax due (line 10 minus line 13).......................................................................... ...................... 14
$
00
15. Penalty, multiply line 14 by 10% (.10) ............................................................................. ......................
$
00
16. Interest, multiply line 14 by ________ ............................................................................ ......................
$
00
17. Amount owed (add lines 14, 15 and 16) 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.
I hereby certify, under penalty of perjury in the second degree, that the statements made herein are, to the best of my knowledge, true and correct.
Signature
Title
Date
Please photocopy and retain copy for your records.
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