1 What type of taxpayer are
2 From whom did you
3 Their Social Security
4 Their Colorado Account
5 Date you received the
6 Total credit available
7 Credit you used in prior
8 Credit available for you
9 Credit you are using this
a transferee
a transferee
for you to use (Enter
Identification Number
Number
Number or Federal
originator
originator
receive each credit?
to next year Line 8 minus
to use this year Line 6
transferor
transferor
year (Enter the Total on
years
(Attach additional
(Total credit amount available from the Remediation of Contaminated Land Certificate issued by CDPHE)
*140349==19999*
10 Credit carried forward
105 Schedule G Line 7
18a if applicable )
24a or form 112CR line
amount transferred OR
and only enter
Colorado Account Number
COLORADO DEPARTMENT OF REVENUE
credit
Credit Amount Available
Credit Use Schedule
Date (MM/DD/YY)
Denver CO 80261 0005
DR 0349 (08/11/14)
e Totals
Entity FEIN
final page )
First Name
For additional information regarding the remediation of contaminated land credit see FYI Income 42 and the
form 104CR Line 24b form
form 106CR Line 13 or
form 112CR Line 18b )
I certify that I meet the requirements of 39 22 526 C R S
Last Name or Business Name
Line 9
Middle Initial
minus Line 7 (Enter the
overall totals on the
Ownership %
pages if necessary
Part A: Use Of Credit Complete this part if you are using or carrying forward credit on this tax return
Pass Through Entity Name
Photocopy and submit additional pages as needed
Remediation of Contaminated Land
Signature
Tax Information Index at www TaxColorado com or contact the Department of Revenue at 303 238 7378
Tax Year Ending
the amount received
the total credit less the
through transfers)
Total on form 104CR Line
www TaxColorado com
you for each credit?
