DR 104EP (08/09/04) Web
COLORADO DEPARTMENT OF REVENUE
DENVER, CO 80261-0008
DO YOU WANT TO AVOID MAILING THESE FORMS?
If so, file and pay your estimated income taxes electronically. With one phone call, you can pay your estimated tax without writing
a check, or mailing anything. When it is time to pay estimated tax, you dial a toll-free number; enter your EFT authorization number,
a password, tax type codes, filing period, and dollar amount. The next day, the money will be transferred to the Department of
Revenue and credited to your account.
To sign up, fill out the form below and send to:
Colorado Department of Revenue
Denver, CO 80261-0005
Sample Check:
9 Digit Routing Number
DETACH FORM
ON THIS LINE
DR 5774 (08/25/04)
EFT AUTHORIZATION
EFT Number
COLORADO DEPARTMENT OF REVENUE
3 7 1 0
DENVER CO 80261-0005
INDIVIDUAL INCOME TAX
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
(303) 205-8333
To be assigned by Department of Revenue
Taxpayer Name
01204
Mailing Address
Social Security Number
City
State
ZIP
Contact Person
Phone
(
)
I authorize the Colorado Department of Revenue,
pursuant to my instructions, to initiate entries to my account number ________________________ at __________________________________ bank.
Name of Bank Account
Type of Account
Checking
Savings
Bank Transit/Routing Number
Signature
Date
A VOIDED CHECK FOR THE BANK ACCOUNT INDICATED ABOVE MUST ACCOMPANY APPLICATION