Form Dr 9596 - Gaming License Renewal Application Form Page 5
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7Colorado Division of Gaming
AUTHORIZATION FOR DISCLOSURE
FOR INTERNAL REVENUE SERVICE
Printed Full Legal Name (Last, First, Middle)
Social Security Number
Home Phone Number
Street Address (Street, City, State, Zip)
Mailing Address (if different from Street Address)
Name and Social Security Number of Person(s) You Have Filed a Joint Tax Return Within Past 5 Years
Type of Return
Form 1040, Individual Income Tax
Taxable Periods
2012, 2013, 2014,2015 and 2016
I authorize the Internal Revenue Service to disclose tax return information (including, but not limited
to, fact of filing, fact of payment, terms of installment agreement) regarding the above returns to the
Division of Gaming, Colorado Department of Revenue.
Signature
Date
For Division of Gaming Use Only
RENEWAL
Date: _______________________________
Initials: ______________________________
Fax Time: ___________________________
Reply Received: ______________________
Mail In: _____________________________
(Revised 04/10/15)
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