Dr 0104ep - Individual Estimated Income Tax (Colorado Department Of Revenue) Page 3

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Departmental Use Only
(0012)
DR 0104EP (09/21/16)
COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0008
2017 Colorado Estimated Income
*170104EP19999*
Tax Payment Form
DO NOT CUT – Return Full Page
(0012)
DR 0104EP (06/02/16)
Return the DR 0104EP with check or money order payable to the Colorado Department of Revenue, Denver, Colorado
80261-0008. Write your Social Security number and “2017 DR 0104EP” on your check or money order. Do not send
cash. Enclose, but do not staple or attach, your payment with this form. File only if you are making a payment of
estimated tax and are unable to pay online or by EFT.
SSN
Your Last Name
Your First Name
Middle Initial
Spouse SSN
Spouse Last Name
Spouse First Name
Middle Initial
Address
City
State
ZIP
Amount of Payment
If No Payment Is Due, Do Not File This Form.
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.
$
.0 0
DO NOT CUT – Return Full Page

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