1040 U.S.

Individual Income Tax Return 2023

Form Department of the Treasury—Internal Revenue Service

OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

For the year Jan. 1–Dec. 31, 2023, or other tax year beginning , 2023, ending , 20 See separate instructions.
Your first name and middle initial Last name Your social security number
peter j colby 149 82 4406
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
PO Box 1923 Check here if you, or your
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code spouse if filing jointly, want $3
to go to this fund. Checking a
Eagle CO 816311923 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

Filing Status Single Head of household (HOH)

Married filing jointly (even if only one had income)
Check only
one box. Married filing separately (MFS) Qualifying surviving spouse (QSS)
If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QSS box, enter the child’s name if the
qualifying person is a child but not your dependent:

Digital At any time during 2023, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell,
Assets exchange, or otherwise dispose of a digital asset (or a financial interest in a digital asset)? (See instructions.) Yes No
Standard Someone can claim: You as a dependent Your spouse as a dependent
Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You: Were born before January 2, 1959 Are blind Spouse: Was born before January 2, 1959 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4) Check the box if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here . .

Income 1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . 1a 46,644.
b Household employee wages not reported on Form(s) W-2 . . . . . . . . . . . . . 1b
Attach Form(s)
W-2 here. Also c Tip income not reported on line 1a (see instructions) . . . . . . . . . . . . . . 1c
attach Forms d Medicaid waiver payments not reported on Form(s) W-2 (see instructions) . . . . . . . . 1d
W-2G and
1099-R if tax e Taxable dependent care benefits from Form 2441, line 26 . . . . . . . . . . . . 1e
was withheld. f Employer-provided adoption benefits from Form 8839, line 29 . . . . . . . . . . . 1f
If you did not g Wages from Form 8919, line 6 . . . . . . . . . . . . . . . . . . . . . 1g
get a Form
W-2, see
h Other earned income (see instructions) . . . . . . . . . . . . . . . . . . 1h 0.
instructions. i Nontaxable combat pay election (see instructions) . . . . . . . 1i
z Add lines 1a through 1h . . . . . . . . . . . . . . . . . . . . . . 1z 46,644.
Attach Sch. B 2a Tax-exempt interest . . . 2a b Taxable interest . . . . . 2b
if required. 3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
Standard
Deduction for— 5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
• Single or 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
Married filing
separately, c If you elect to use the lump-sum election method, check here (see instructions) . . . . .
$13,850 7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . 7
• Married filing
jointly or 8 Additional income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . 8 0.
Qualifying
surviving spouse, 9 Add lines 1z, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . . 9 46,644.
$27,700 10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10
• Head of
household, 11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . . 11 46,644.
$20,800
• If you checked
12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 13,850.
any box under 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
Standard
Deduction, 14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . 14 13,850.
see instructions.
15 Subtract line 14 from line 11. If zero or less, enter -0-. This is your taxable income . . . . . 15 32,794.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2023)
Form 1040 (2023) Page 2

Tax and 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 3,713.
Credits 17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 3,713.
19 Child tax credit or credit for other dependents from Schedule 8812 . . . . . . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 3,713.
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 0.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . . 24 3,713.
Payments 25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 3,786.
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 3,786.
If you have a 26 2023 estimated tax payments and amount applied from 2022 return . . . . . . . . . . 26
qualifying child, 27 Earned income credit (EIC) . . . . . . . . . . . .No. . 27
attach Sch. EIC.
28 Additional child tax credit from Schedule 8812 . . . . . . . . 28
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Reserved for future use . . . . . . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31
32 Add lines 27, 28, 29, and 31. These are your total other payments and refundable credits . . 32
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . . 33 3,786.
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 73.
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . 35a 73.
Direct deposit? b Routing number 1 0 3 1 0 0 1 9 5 c Type: Checking Savings
See instructions.
d Account number 2 4 8 1 5 6 5 5 3 3 1 0
36 Amount of line 34 you want applied to your 2024 estimated tax . . . 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe.
You Owe For details on how to pay, go to www.irs.gov/Payments or see instructions . . . . . . . . 37
38 Estimated tax penalty (see instructions) . . . . . . . . . . 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . . Yes. Complete below. No
Designee’s Phone Personal identification
name no. number (PIN)

Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
Joint return? Security Guard (see inst.)
See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.)

Phone no. (908)328-7962 Email address

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer
Firm’s name Self-Prepared Phone no.
Use Only
Firm’s address Firm’s EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 02/16/24 Intuit.cg.cfp.sp Form 1040 (2023)
 DR 8454 (09/28/23)
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261-0005
Tax.Colorado.gov
238454 11555 Page 1 of 1

State of Colorado Income Tax Declaration

for Online Electronic Filing
Do not mail WKLVIRUPWRWKH,56RUWKH&RORUDGR )RU7D[<HDU 00''<< RU)LVFDO<HDUEHJLQQLQJ 00''<<
'HSDUWPHQWRI5HYHQXHRetain with your records. 12/31/23

7D[7\SH

X ,QGLYLGXDO,QFRPH &RUSRUDWH,QFRPH 3DUWQHUVKLS6&RUS,QFRPH )LGXFLDU\,QFRPH

(DR 0104) (DR 0112) (DR 0106) (DR 0105)
7D[SD\HU/DVW1DPHRU%XVLQHVV1DPH )LUVW1DPHRU%XVLQHVV'%$LIGLIIHUHQWIURP%XVLQHVV1DPH 0LGGOH,QLWLDO

COLBY PETER J
6SRXVH V/DVW1DPH LIDSSOLFDEOH )LUVW1DPH 0LGGOH,QLWLDO

7D[SD\HU661RU,7,1 6SRXVH661RU,7,1 LIDSSOLFDEOH )(,1

149-82-4406
7D[SD\HURU%XVLQHVV$GGUHVV City 6WDWH =,3

PO BOX 1923 EAGLE CO 81631-1923

Part I — Tax Return Information
46644
1. 7RWDO,QFRPHIURP\RXUIHGHUDOUHWXUQ VHHLQVWUXFWLRQVIRUPRUHLQIRUPDWLRQ 1 $
2. 7D[DEOH,QFRPH RUDOORZDEOHGHGXFWLRQ IURP\RXUIHGHUDOUHWXUQ VHHLQVWUXFWLRQV
32794
IRUPRUHLQIRUPDWLRQ 2 $
1441
3. &RORUDGR7D[IURP\RXU&RORUDGRUHWXUQ VHHLQVWUXFWLRQVIRUPRUHLQIRUPDWLRQ 3 $
4. &RORUDGR7D[:LWKKHOGRU3D\PHQWVIURP\RXU&RORUDGRUHWXUQ VHHLQVWUXFWLRQV
1850
RUPRUHLQIRUPDWLRQ 4 $
Part II — Declaration of Tax Payer
8QGHUSHQDOWLHVRISHUMXU\,GHFODUHWKDWWKHLQIRUPDWLRQ,KDYHSURYLGHGIRUHOHFWURQLF¿OLQJDQGWKHDPRXQWVVKRZQLQ3DUW,DERYHDJUHHZLWKWKHDPRXQWVVKRZQRQP\
)HGHUDO&RORUDGRLQFRPHWD[UHWXUQVDQGWKDWVDLGWD[UHWXUQVVWDWHPHQWVVFKHGXOHVDQGDWWDFKPHQWVDUHWUXHFRUUHFWDQGFRPSOHWHWRWKHEHVWRIP\NQRZOHGJHDQGEHOLHI
,XQGHUVWDQGWKDW, RUP\(OHFWURQLF5HWXUQ2ULJLQDWRU (52 LIDSSOLFDEOH PD\EHUHTXLUHGWRSURYLGHSDSHUFRSLHVRIWKLVGHFODUDWLRQP\UHWXUQVZLWKKROGLQJVWDWHPHQWV
VFKHGXOHVDQGDWWDFKPHQWVXSRQUHTXHVWE\WKH&RORUDGR'HSDUWPHQWRI5HYHQXHDWDQ\WLPHGXULQJWKHSHULRGFRYHUHGE\WKH&RORUDGRVWDWXWHRIOLPLWDWLRQV
6LJQDWXUH 'DWH 00''<<

6SRXVH V6LJQDWXUH ,I-RLQW5HWXUQ%RWK0XVW6LJQ 'DWH 00''<<

Part III — Declaration of ERO/Preparer/Transmitter

,IWKHWUDQVPLWWHUGLGQRWSUHSDUHWKHWD[UHWXUQFKHFNKHUH X

,I,DPQRWWKHSUHSDUHU,GHFODUHRQO\WKDWWKHDPRXQWVVKRZQLQ3DUW,DERYHDJUHHZLWKWKHDPRXQWVVKRZQRQWKHWD[SD\HU V)HGHUDO&RORUDGRLQFRPHWD[UHWXUQV,I,DP
WKHSUHSDUHUXQGHUSHQDOWLHVRISHUMXU\,GHFODUHWKDW,KDYHUHYLHZHGWKHDERYHWD[SD\HU V)HGHUDO&RORUDGRLQFRPHWD[UHWXUQVDQGWKDWWKHLQIRUPDWLRQSURYLGHGWRPHE\WKH
WD[SD\HUDQGWKHDPRXQWVVKRZQLQ3DUW,DERYHDJUHHZLWKWKHDPRXQWVVKRZQRQVDLGWD[UHWXUQVDQGWKDWVDLGWD[UHWXUQVVWDWHPHQWVVFKHGXOHVDQGDWWDFKPHQWVDUHWUXH
FRUUHFWDQGFRPSOHWHWRWKHEHVWRIP\NQRZOHGJHDQGEHOLHI$VSUHSDUHU,IXUWKHUGHFODUHWKDW,KDYHREWDLQHGWKHWD[SD\HU VVLJQDWXUHRQWKLVIRUPDWWKHWLPHRI¿OLQJDQG
KDYHSURYLGHGWKHWD[SD\HUZLWKFRSLHVRIDOOIRUPVDQGLQIRUPDWLRQ¿OHG,DOVRDJUHHWRPDLQWDLQWKLVVLJQHG)RUP '5 IRUWKHSHULRGFRYHUHGE\WKH&RORUDGRVWDWXWH
RIOLPLWDWLRQVDQGWRSURYLGHSDSHUFRSLHVRIWKLVGHFODUDWLRQVDLGUHWXUQVZLWKKROGLQJVWDWHPHQWVVFKHGXOHVDQGDWWDFKPHQWVXSRQUHTXHVWE\WKH&RORUDGR'HSDUWPHQWRI
5HYHQXHDWDQ\WLPHGXULQJWKLVSHULRG
(52 V6LJQDWXUH 3UHSDUHU,GHQWL¿FDWLRQ1XPEHU<RXU661RU,7,1

SELF-PREPARED
'DWH 00''<<
&KHFNLIDOVR3UHSDUHU

REV 01/22/24 INTUIT.CG.CFP.SP

 230104 11555
DR 0104 (11/28/23)
COLORADO DEPARTMENT OF REVENUE
Tax.Colorado.gov
Page 1 of 4
(0013)

2023 Colorado Individual Income Tax Return

X Full-Year Part-Year or Nonresident (or resident, part-year, Mark if Abroad on due date –
non-resident combination) *Must include DR 0104PN see instructions
Your Last Name Your First Name Middle Initial

COLBY PETER J
Date of Birth (MM/DD/YYYY) SSN or ITIN Deceased
If checked and claiming a refund, you must include
01/29/1982 149-82-4406
WKH'5DQGGHDWKFHUWL¿FDWHZLWK\RXUUHWXUQ
State of Issue Last 4 characters of ID number Date of Issuance
(QWHUWKHIROORZLQJLQIRUPDWLRQIURP\RXUFXUUHQW
GULYHUOLFHQVHRUVWDWHLGHQWL¿FDWLRQFDUG CO 9186 09/16/20
If Joint, Spouse’s Last Name Spouse’s First Name Middle Initial

Spouse’s Date of Birth (MM/DD/YYYY) Spouse’s SSN or ITIN Deceased

If checked and claiming a refund, you must include
WKH'5DQGGHDWKFHUWL¿FDWHZLWK\RXUUHWXUQ
State of Issue Last 4 characters of ID number Date of Issuance
(QWHUWKHIROORZLQJLQIRUPDWLRQIURP\RXUVSRXVH¶V
FXUUHQWGULYHUOLFHQVHRUVWDWHLGHQWL¿FDWLRQFDUG
Mailing Address Phone Number

PO BOX 1923 (908)328-7962

City State ZIP Code Foreign Country (if applicable)

EAGLE CO 81631-1923

To see if you or members of your household qualify for free or reduced-cost health coverage, check this box if:
• You are a Colorado resident and at least one person in your household does not have health coverage
AND
• <RXJLYHSHUPLVVLRQIRUWKH&RORUDGR'HSDUWPHQWRI5HYHQXHWRVKDUHWKHLQIRUPDWLRQRQ)RUP'5((ZLWK&RQQHFW
IRU+HDOWK&RORUDGR WKH&RORUDGR+HDOWK%HQH¿W([FKDQJH DQGWKH'HSDUWPHQWRI+HDOWK&DUH3ROLF\ )LQDQFLQJ
Round To The Nearest Dollar
1. Enter Federal Taxable Income from your federal income tax form: 32794
1040, 1040 SR, or 1040 SP 1 00
,QFOXGH:VDQGVZLWK&2ZLWKKROGLQJ
Additions to Federal Taxable Income
2. State and Local Income taxes or general sales taxes claimed on federal form 1040,
6FKHGXOH$ VHHLQVWUXFWLRQV  2 00

3. 4XDOL¿HG%XVLQHVV,QFRPH'HGXFWLRQ$GGEDFN VHHLQVWUXFWLRQV 3 00

REV 01/22/24 INTUIT.CG.CFP.SP

 DR 0104 (11/28/23)
COLORADO DEPARTMENT OF REVENUE
Tax.Colorado.gov
Page 2 of 4
230104 21555
Name SSN or ITIN

PETER J COLBY 149-82-4406

4. Federal Deduction addback (see instructions) 4 00

5. 1RQTXDOL¿HG&ROOHJH,QYHVW7XLWLRQ6DYLQJV$FFRXQWGLVWULEXWLRQV
(see instructions) 5 00

6. 1RQTXDOL¿HG&RORUDGR$%/($FFRXQWGLVWULEXWLRQV VHHLQVWUXFWLRQV 6 00

7. 2WKHU$GGLWLRQVH[SODLQ VHHLQVWUXFWLRQV 7 00
Explain:

32794
8. Subtotal, sum of lines 1 through 7 8 00
Colorado Subtractions
9. Subtractions from the DR 0104AD Schedule, line 23, you must submit the
0
'5$'VFKHGXOHZLWK\RXUUHWXUQ 9 00
32794
10. Colorado Taxable Income, subtract line 9 from line 8 10 00
Tax, Prepayments and Credits: see 104 Book for full-year tax table and part-year DR 0104PN Schedule
11. Colorado Tax from tax table or the DR 0104PN line 36, you must submit the
1441
'531ZLWK\RXUUHWXUQLIDSSOLFDEOH 11 00
12. Alternative Minimum Tax from the DR 0104AMT line 8, you must submit the
'5$07ZLWK\RXUUHWXUQ 12 00

13. Recapture of prior year credits 13 00

1441
14. Subtotal, sum of lines 11 through 13 14 00
15. Nonrefundable Credits from the DR 0104CR line 54, the sum of lines 15, 16, and 17
cannot exceed line 14\RXPXVWVXEPLWWKH'5&5ZLWK\RXUUHWXUQ 15 00
16. Total Nonrefundable Enterprise Zone credits used – as calculated, or from the
DR 1366 line 85, the sum of lines 15, 16, and 17 cannot exceed line 14, you must
VXEPLWWKH'5ZLWK\RXUUHWXUQ 16 00
17. Strategic Capital Tax Credit from DR 1330, the sum of lines 15, 16, and 17 cannot
exceed line 14\RXPXVWVXEPLWWKH'5ZLWK\RXUUHWXUQ 17 00
1441
18. Net Income Tax, sum of lines 15, 16, and 176XEWUDFWWKDWVXPIURPline 14 18 00
19. Use Tax reported on the DR 0104US schedule line 7, you must submit the
'586ZLWK\RXUUHWXUQ 19 00
1441
20. Net Colorado Tax, sum of lines 18 and 19 20 00
21. &2,QFRPH7D[:LWKKHOGIURP:VDQGV\RXPXVWVXEPLWWKH:VDQGRU
1850
VFODLPLQJ&RORUDGRZLWKKROGLQJZLWK\RXUUHWXUQ 21 00

22. 3ULRU\HDU(VWLPDWHG7D[&DUU\IRUZDUG 22 00
23. Estimated Tax Payments, enter the sum of the quarterly payments remitted for
this tax year 23 00

24. ([WHQVLRQ3D\PHQWUHPLWWHGZLWKWKH'5, 24 00

REV 01/22/24 INTUIT.CG.CFP.SP

 DR 0104 (11/28/23)
COLORADO DEPARTMENT OF REVENUE
Tax.Colorado.gov
Page 3 of 4
230104 31555
Name SSN or ITIN

PETER J COLBY 149-82-4406

25. 2WKHU3UHSD\PHQWV DR 0104BEP DR 0108 DR 1079 25

00
26. Gross Conservation Easement Credit from the DR 1305G line 33, you must submit
WKH'5*ZLWK\RXUUHWXUQ 26 00
27. Innovative Motor Vehicle and Innovative Truck Credit from form DR 0617, you must 0
VXEPLWHDFK'5ZLWK\RXUUHWXUQ 27 00
28. Refundable Credits from the DR 0104CR line 16, you must submit the DR 0104CR
ZLWK\RXUUHWXUQ 28 00
1850
29. Subtotal, sum of lines 21 through 28 29 00
0RGL¿HG$*,IRU7$%25
Lines 30 through 33DUHRQO\XVHGWRFDOFXODWH\RXU7$%25&UHGLWWKH\GRQRWDIIHFW\RXU&RORUDGRWD[OLDELOLW\
30. Federal Adjusted Gross Income from your federal income tax form: 1040, 1040 SR, 46644
or 1040 SP 30 00

31. Nontaxable Social Security Income 31 00

32. Nontaxable interest income from state and local bonds 32 00

46644
33. Sum of lines 30 through 320RGL¿HG$*,IRU7$%25 33 00

This space is reserved for future use.

34. State Sales Tax Refund: For full-year Colorado residents, born before 2005, or
IXOO\HDU&RORUDGRUHVLGHQWVZKRDUHXQGHUWKHDJHRIHLJKWHHQEXWDUHUHTXLUHG
800
WR¿OHDUHWXUQ(QWHUIRURQHTXDOLI\LQJWD[SD\HURUIRUWZRTXDOLI\LQJ
WD[SD\HUV¿OLQJMRLQWO\6HHLQVWUXFWLRQVLI\RXDUH¿OLQJDQH[WHQVLRQ 34 00
2650
35. Sum of lines 29 and 34 35 00
1209
36. 2YHUSD\PHQWLIline 35 is greater than line 20 then subtract line 20 from line 35 36 00

37. (VWLPDWHG7D[&UHGLW&DUU\IRUZDUGWR¿UVWTXDUWHULIDQ\ 37 00

If you have an overpayment on line 38EHORZDQGZRXOGOLNHWRGRQDWHDOORUDSRUWLRQRI\RXURYHUSD\PHQWWRDTXDOL¿HG

&RORUDGRFKDULW\LQFOXGH)RUP'5&+WRFRQWULEXWH

1209
38. Refund, subtract line 37 from line 36 (see instructions) 38 00

Routing Number Type: X Checking Savings CollegeInvest 529

Direct 1 0 3 1 0 0 1 9 5

Deposit Account Number 2 4 8 1 5 6 5 5 3 3 1 0

For questions regarding CollegeInvest direct deposit or to open an account, visit CollegeInvest.org or call 800-448-2424.

REV 01/22/24 INTUIT.CG.CFP.SP

 DR 0104 (11/28/23)
COLORADO DEPARTMENT OF REVENUE
Tax.Colorado.gov
Page 4 of 4
230104 41555
Name SSN or ITIN

PETER J COLBY 149-82-4406

39. Net Tax Due, subtract line 35 from line 20 39 00

40. Delinquent Payment Penalty (see instructions) 40 00

41. Delinquent Payment Interest (see instructions) 41 00

42. (VWLPDWHG7D[3HQDOW\\RXPXVWVXEPLWWKH'5ZLWK\RXUUHWXUQ
(see instructions) 42 00

43. $PRXQW<RX2ZHVXPRIlines 39 through 42 43

7KH6WDWHPD\FRQYHUW\RXUFKHFNWRDRQHWLPHHOHFWURQLFEDQNLQJWUDQVDFWLRQ<RXUEDQNDFFRXQWPD\EHGHELWHGDVHDUO\DVWKHVDPHGD\UHFHLYHG
E\WKH6WDWH,IFRQYHUWHG\RXUFKHFNZLOOQRWEHUHWXUQHG,I\RXUFKHFNLVUHMHFWHGGXHWRLQVXI¿FLHQWRUXQFROOHFWHGIXQGVWKH'HSDUWPHQWRI
5HYHQXHPD\FROOHFWWKHSD\PHQWDPRXQWGLUHFWO\IURP\RXUEDQNDFFRXQWHOHFWURQLFDOO\
Third Party Designee
'R\RXZDQWWRDOORZDQRWKHUSHUVRQWRGLVFXVVWKLV
UHWXUQDQGDQ\UHODWHGLQIRUPDWLRQZLWKWKH&RORUDGR X No <HV&RPSOHWHWKHIROORZLQJ
'HSDUWPHQWRI5HYHQXH"6HHWKHLQVWUXFWLRQV
Designee’s Name Phone Number

Sign Below 8QGHUSHQDOWLHVRISHUMXU\,GHFODUHWKDWWRWKHEHVWRIP\NQRZOHGJHDQGEHOLHIWKLVUHWXUQLVWUXHFRUUHFWDQGFRPSOHWH

Your Signature Date (MM/DD/YY)

6SRXVH¶V6LJQDWXUH,IMRLQWUHWXUQ%27+PXVWVLJQ Date (MM/DD/YY)

Paid Preparer’s Name Paid Preparer’s Phone

SELF PREPARED
Paid Preparer’s Address City State ZIP Code

REV 01/22/24 INTUIT.CG.CFP.SP

File and pay at: Colorado.gov/RevenueOnline

,I\RXDUH¿OLQJWKLVUHWXUQwith a check or ,I\RXDUH¿OLQJWKLVUHWXUQwithout a check or

payment, please mail the return to: payment, please mail the return to:
&2/25$'2'(3$570(172)5(9(18( &2/25$'2'(3$570(172)5(9(18(
'HQYHU&26 'HQYHU&25

7KHVHDGGUHVVHVDQG]LSFRGHVDUHH[FOXVLYHWRWKH&RORUDGR'HSDUWPHQWRI5HYHQXHVRDVWUHHWDGGUHVVLVQRWUHTXLUHG