Form Dr 0241 - Application For Fuel Tax Exemption Certificate For Government Or Political Subdivision

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DR 0241 (11/19/04)
DEPARTMENTAL USE ONLY
27
COLORADO DEPARTMENT OF REVENUE
DENVER CO 80261-0016
(303) 205-8205
APPLICATION FOR FUEL TAX
EXEMPTION CERTIFICATE
for Government or Political Subdivision
Name
Physical Address
City
State
ZIP
County
City Limits In Which Located (if applicable)
Telephone
Mailing Address (if different from above)
City
State
ZIP
County
Telephone (If different from above)
FEIN
Political Subdivision
School District
Registration Number
Period
Liability Codes
5460-760 (999) $0.00
CERTIFICATION:
I/we certify and declare that this application is true and correct and that it is made under penalty of perjury in the second degree.
Signature
Date
Title
Phone Number

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