DR 0096 (08/28/13)
COLORADO DEPARTMENT OF REVENUE
Business Tax Accounting, Room 208
PO Box 17087
Denver, CO 80217-0087
(303) 238-SERV (7378)
Request For Tax Status Letter
In accordance with the provision of § 38–25.5, C.R.S., I hereby request that the Department if Revenue issue a tax
status letter.
Last Name of Taxpayer/DBA First Name of Taxpayer/DBA Middle Initial
Address City State Zip
Mailing Address City State Zip
Colorado Account Number(s) FEIN Phone Number
( )
Type of Taxes
List only taxes that are remitted to the Colorado Department of Revenue.*
Corporate Income Consumer Use SCFD Sales County Sales
State Sales State Withholding Football Sales Retailers Use
City Sales RTD Sales County Lodging Severance
Make Check Payable To:
Department of Revenue
To Be Paid Before Issuance of the Clearance
Please make a copy for your records.
Fee: $7.00 Per Tax
Total Remitted
The state may convert your check to a one time electronic banking transaction. Your bank account may
be debited as early the same day received by the State. If converted, your check will not be returned. If
your check is rejected due to insufcient or uncollected funds, the Department of Revenue may collect
the payment amount directly from your bank account electronically.
*
Tax status letters are not available for individual income tax. Do Not send this form or payment as a request
for an individual income
tax status letter.
If liability for any other tax exists and reports have not been led, the tax may be assessed at any time. The issuance of this letter does
not x, abate, modify, or cancel any liability or payment of money due or performance of an obligation to the State of Colorado.
I declare under the penalty of perjury in the second degree that I am a duly authorized ofcer of the corporation for which this tax status
letter is requested and that I am acting in my ofcial capacity in making this request.
Authorization/Power of Attorney must be attached to this request if applicable.
Name Title
Signature Date
(MM/DD/YY)
*130096==19999*
