Form Dr 1585 - Application For Liquefield Petroleum Gas Or Natural Gas Decal
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1
2APPLICATION FOR LIQUEFIED PETROLEUM
DR 1585 (03/22/11)
Departmental Use Only
COLORADO DEPARTMENT OF REVENUE
GAS OR NATURAL GAS DECAL
DENVER, CO 80261-0009
(303) 205-8205
Name
Location Address
Mailing Address
City
State
ZIP
City
State
ZIP
F.E.I.N or Social Security Number
Account Number
5560-760
Liabillty Date (1st month of operation)
Period (MM/YY-MM/YY)
A. Vehicles with a gross weight of 10,000 pounds or less
FEE Per vehicle fee for number of complete or partial months remaining in the calendar year
12
11
10
9
8
7
6
5
4
3
2
1
70.00
64.17
58.33
52.50
46.67
40.83
35.00
29.17
23.33
17.50
11.67
5.83
Vehicle Identification Number State License Plate No.
Make
Year Purchase Date Gross Vehicle Wt.
Fee
Total
Total A. Fees Paid and Decals ordered. Enter total decals & amount
Decals (892)
•
•
Total Fee (100)
$
B. Vehicles with a gross weight of 10,001 – 16,000 pounds
FEE Per vehicle fee for number of complete or partial months remaining in the calendar year
12
11
10
9
8
7
6
5
4
3
2
1
100.00
91.67
83.33
75.00
66.67
58.33
50.00
41.67
33.33
25.00
16.67
8.33
Vehicle Identification Number State License Plate No.
Make
Year Purchase Date Gross Vehicle Wt.
Fee
Total
Total B. Fees Paid and Decals ordered. Enter total decals & amount
Decals (894)
•
•
Total Fee (120)
$
C. Vehicles with a gross weight of over 16,000 pounds
FEE Per vehicle fee for number of complete or partial months remaining in the calendar year
12
11
10
9
8
7
6
5
4
3
2
1
125.00
114.58
104.17
93.75
83.33
72.92
62.50
52.08
41.67
31.25
20.83
10.42
Vehicle Identification Number State License Plate No.
Make
Year Purchase Date Gross Vehicle Wt.
Fee
Total
Total C. Fees Paid and Decals ordered. Enter total decals & amount
Decals (896)
•
•
Total Fee (130)
$
Date
I certify under penalty of perjury in the second degree that to the
If you need additional space please photocopy this form.
best of my knowledge the above information is true and correct.
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.
Signature of Applicant
Telephone
(355)
Amount Owed
•
$
.
(ADD TOTALS FROM A,B,& C)
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