Form Dr 0021w - Oil And Gas Withholding Statement
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1DR 0021W (09/27/11) WEB
oil and Gas Withholding Statement
Colorado department of revenue
Denver CO 80261-0007
for Calendar Year 20__
inStruCtionS for produCerS and firSt
inStruCtionS for reCipientS of dr 0021W
purChaSerS preparinG dr 0021W for SeveranCe
Any producer, working, royalty or other interest owner of oil and
taXpaYerS
gas produced in Colorado is required to pay severance tax. Every
producer or first purchaser is required to withhold 1% of the
Box 1–5 Enter the information requested.
gross income paid to every owner, and to supply an Oil and Gas
line 6
Enter the total gross income (before 1% withholding, ad
Withholding Statement by March 1 of each year.
valorem, etc.,) made to the interest owner on both a cash
basis and accrual basis. For cash basis, report all
This Oil and Gas Withholding Statement form lists your gross
payments made during the year even if they are for prior
income from the property indicated and the amount the producer
period production or are take or pay payments for future
or first purchaser has withheld. It also lists your share of any ad
production. For accrual basis, report payments on all
valorem taxes paid.
production during the calendar year, even if they are not
You must attach one copy of this form to your “Colorado Severance
disbursed to the interest owner within the year.
Tax Return” (DR 0021) in order to claim credits. If you need
Enter that portion of payments, on both the cash and accrual
line 7
additional information about severance tax, see publication FYI
basis, that are from tax-exempt oil and gas production
General 4, "Severance Tax Information for Owners of any Interest
from a stripper well.
in any Oil and Gas Produced in Colorado," on our Web site
Enter the amount of ad valorem tax on both cash and
line 8
accrual basis. For cash basis, report only ad valorem taxes
actually paid to the county assessors during the year. For
accrual basis, report the actual ad valorem tax amount
assessed at the mill levy date (usually in November or
December) within the year.
Enter that amount of ad valorem tax for both the cash and
line 9
accrual basis that related to oil and gas production from
a stripper well.
Enter amount of severance tax actually withheld and remitted
line 10
to Colorado Department of Revenue for the calendar year.
Box 11
Enter information as required.
and 12
THIS FORM MAY BE REPRODUCED IN THIS FORMAT IN A MANNER COMPATIBLE WITH COMPUTER GENERATION.
DETACH FORM
ON THIS LINE
Photocopy for your records.
Cut here and send only the coupon below. Help us save time and your tax dollars.
DR 0021W (09/27/11) WEB
oil and Gas Withholding Statement for Calendar Year 20____
Colorado department of revenue
Colorado Severance tax Withheld from oil Shale and oil/Gas payments
Denver CO 80261-0007
1. Well Name
4. County
2. Lease
5. American Petroleum
Institute Well Number
3. Field
See aBove for inStruCtionS
CaSh BaSiS
aCCrual BaSiS
$
$
6. Gross income ...............................................................................................
7. Gross income attributable to stripper
$
$
well production .............................................................................................
8. Ad valorem tax on oil and gas
$
$
production .....................................................................................................
9. Ad valorem tax attributable to
$
$
stripper well production ................................................................................
$
10. Severance tax withheld .............................................................................................................
If filing on a fiscal period, this information is not correct. Consult your distribution statements or payor for correct amounts.
11. Name, Address and Social Security or Colorado Account No. of Payee:
12. Name, Address and Colorado Account No. or FEIN of Payor:
note to paYor: Attach one copy to the DR 0456. Retain a copy for
your records. Submit two copies to payee.
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