Reminders
Please be sure to submit copies of all DR 0021W forms
with the DR 0456 return.
If you led 12 consecutive months of zero returns, you
should close your account.
Be sure to round all amounts to the nearest dollar. Make
sure the amount of your payment matches the amount
listed on line 19 on the form.
Lines 1–12
The total oil and gas severance taxes withheld per the
DR 0021W(s).
Line 13
Total severance taxes withheld and remitted to the
Colorado Department of Revenue during the calendar year.
Line 14
The total on line 14 should match the amount of Colorado
severance tax withheld from all DR 0021W forms issued.
Line 15
Line 14 minus line 13; this will be the additional severance
withholding tax due.
Line 16
Line 13 minus line 14; this will be any refund due.
Line 17
Failure to le a return and pay the tax on or before the
due date will result in a penalty at the rate of 30% or $30,
whichever is greater, per §39-29-115(1), C.R.S.
Line 18
Failure to le a return and pay the tax on or before the due
date will result in interest at the current statutory rate from
the due date of payment. See FYI publication - General 11
for more information.
Line 19
Total amount owed with this report. You must round to the
nearest dollar.
Please see FYI publication - Withholding 4, Colorado Oil
and Gas Severance Withholding Requirements. For further
information call (303) 238-SERV (7378) or visit the Ofcial
Taxation Web site, Tax.Colorado.gov
Colorado Annual Reconciliation Of Oil and Gas Severance Withholding
Instructions and Information
(See form on page 2)
DR 0456 (07/23/21)
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261-0006
Tax.Colorado.gov
This reconciliation must be led with the Colorado
Department of Revenue on or before April 15, following the
close of the calendar year. Copies of each DR 0021W, Oil
and Gas Withholding Statement, that was issued by this
entity must also accompany this form. Unless the production
is exempt from tax, a DR 0021W must be issued to any
person or entity with a working interest, royalty interest,
production payment, or any other interest in the oil or gas
that was produced in Colorado.
Failure to le this Annual Reconciliation and/or the
accompanying DR 0021W forms can result in a penalty of
15% or $1,500, whichever is less.
The DR 0021W forms can be submitted electronically via
Revenue Online at www.Colorado.gov/RevenueOnline
Please review FYI publication - Withholding 9 for ling
specications. This form DR 0456 should be submitted to
the address shown below.
COLORADO DEPARTMENT OF REVENUE
Denver, CO 80261-0006
This addresses and zip code is exclusive to the Colorado
Department of Revenue, so a street address is not required.
List the total monthly oil and gas
severance tax withheld
1. January 1
00
2. February
2
00
3. March
3
00
Mail to and Make Checks Payable to:
Colorado Department of Revenue
Denver Colorado 80261-0006
4. April
4
00
Instructions: The DR 0456 must be led with the Colorado Department
of Revenue on or before April 15, following the close of the calendar year.
The Oil and Gas Withholding Statement (DR 0021W) must be submitted for
each person who had Colorado gross severance tax withheld from oil and
gas payments during the calendar year.
5. May
5
00
6. June
6
00
7. July
7
00
Last Name or Business Name First Name Middle Initial
8. August 8
00
Address
9. September 9
00
City State ZIP
10. October 10
00
FEIN Colorado Account Number
11. November 11
00
Period Ending (YYYY)
Dec. 31 20
Due Date (YYYY)
April 15 20
12. December
12
00
13. Total Colorado severance taxes remitted to the Department of Revenue during the year
13
00
14. Sum of Colorado severance tax withheld from all
DR 0021W forms issued
Quantity of DR 0021W forms prepared
14
00
15. Additional severance withholding tax due (line 14 minus line 13)
15
00
16. Refund (line 13 minus line 14)
16
00
17. Penalty
(see instructions
)
17
00
18. Interest % per month
18
00
19. Total Amount Owed with this report
Paid by EFT
19
$
.00
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 insufcient or uncollected funds, the Department of Revenue may collect the payment amount directly from your bank account electronically.
I certify that under penalty of perjury in the second degree that to the best of my knowledge the above information is true and correct.
Name of Business or Taxpayer Date (MM/DD/YY)
Signature of Taxpayer or Corporate Ofcer Date (MM/DD/YY)
Submit copies of all DR 0021W forms with this return
Colorado Annual Reconciliation Of Oil
and Gas Severance Withholding
DR 0456 (07/23/21)
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261-0006
Tax.Colorado.gov
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