Form Dr 1091 - Backup Withholding Tax Return-Gaming
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1
2DR 1091 Web (06/09/11)
COLORADO DEPARTMENT OF REVENUE
Taxpayer Services
1375 Sherman Street
Denver, Colorado 80261-0009
Backup Withholding Tax Return – Gaming
(Includes slot machines, bingo, and horse and dog racing)
Instructions
Please return the completed and signed lower portion of the return. Be sure the entire from is complete. Return
must be filed monthly even when no tax is due.
If you are filing an amended return you are required to
ment on line 8. Overpayment must not result
check the amended return box. A separate amended
in a negative balance.
return must be filed for each period. The amended return
Line 9:
Enter the total amount due (line 6 plus line 7
must show all tax columns as corrected, not merely the
or minus line 8).
difference(s). The amended return will replace the original
HOW TO FILE A RETURN:
return in its entirety.
This return, together with remittance by check, draft or
Line 1:
Enter the total state tax withheld on line 14 of
money order made payable to the Colorado Department
all Federal forms W-2G.
of Revenue, must be filed with the
Line 2:
Enter the total state income tax withheld from
Colorado Department of Revenue
non-resident aliens on line 12 of Federal form
1375 Sherman St.
1042S.
Denver, CO 80261-0009
Line 3:
Enter the total of lines 1 and 2.
on or before the 15th day of the month following the close
Lines 4&5: Failure to file the return and pay the tax on
of the taxable period. Mailed returns must be postmarked
time subjects the vendor to a penalty of 5% +
the 15th day of the month or prior thereto.
1/2% per month with the maximum being 12%
or a minimum of $5.00. Interest is due at the
HOW TO REMIT W-2G FORMS:
current statutory rate.
The Colorado copies of the W-2G forms must be sent
Line 6:
Enter the total of lines 3, 4 and 5.
to the attention of Discovery Section, Colorado Dept. of
Line 7:
If an under payment of tax was made on a
Revenue, 1375 Sherman St., Denver, Colorado 80261-
previous return, enter the amount of under-
0009. Forms can be remitted as often as monthly but have
payment plus penalty and interest line 7.
to be remitted annually at a minimum. DO NOT SEND
Line 8:
If an overpayment of tax was made on a pre-
W-2G FORMS WITH THIS RETURN.
vious return, enter the amount of the overpay-
Any questions regarding the preparation of this return may
be directed to (303) 238-SERV (7378).
Photo Copy For Your Records
Cut here and send only the coupon below. Help us save time and your tax dollars.
7
DR 1091 Web (06/09/11)
Backup Withholding Tax Return–Gaming
COLORADO DEPARTMENT OF REVENUE
1010-100
Account Number
Period
Due Date
1. Resident income tax withheld
00
Line 14-12G
Social Security Number 1
Social Security Number 2
FEIN
2. Nonresident income tax withheld
00
Line 12-04S
Signed under penalty of perjury in the second degree.
00
(100)
3. Total of lines 1 and 2
Signature
Date
Phone
(
)
00
(200)
4. Penalty
Check here if this is an Amended Return ..
00
(300)
5. Interest
00
6. Total of lines 3, 4 & 5
7. Additional tax, penalty & interest
due for prior periods of current
00
year only.
(900)
8. Overpayment of tax for prior tax
periods of current year to be
The State may convert your check to a one time electronic banking transaction. Your bank account may be debited
00
subtracted from current tax.
(905)
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
9. AMOUNT OWED (line 6 plus line
your bank account electronically.
$
.00
7 or minus line 8)
(355)
(Do not write in space below)
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