Request For Administrative Review Of Income Tax Offset
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1County Court
District Court
__________________________County, Colorado
Court Address:
People of the State of Colorado
v.
COURT USE ONLY
Defendant: _________________________________
Social Security Number: _______________________________
Case Number:
Email Address: ______________________________________
_______________________________
REQUEST FOR ADMINISTRATIVE REVIEW OF INCOME TAX OFFSET
1. I have received a notice from the Department of Revenue, State of Colorado, informing me that my state
income tax return, or a portion thereof, has been offset for payment of court-ordered fines, costs and/or
restitution, in accordance with §§16-11-101.8 and 16-18.5-106.8, C.R.S. A copy of the notice is attached.
2. I hereby request an administrative review of this income tax offset for the following reason (select one box
below; a brief comment may be included):
I am not required to pay fines, costs and/or restitution to this court.
_____________________________________________________________________________________
_____________________________________________________________________________________
The amount of fines, costs and/or restitution owed to the court is not correct.
_____________________________________________________________________________________
_____________________________________________________________________________________
Other: _______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
3. This request is made within thirty (30) days from the date I received the notice of income tax offset from the
Department of Revenue.
Date: ______________________________
_____________________________________
Signature
______________________________________
Address
______________________________________
City
State
Zip Code
______________________________________
Home Phone #
Cell #
COURT USE ONLY
As a result of an administrative review of your tax offset:
It has been determined that the tax offset was appropriate. The amount owed is $___________.
A copy of the court’s case financial record is attached.
It has been determined that you are owed a refund. A refund in the amount of $ ________ will be sent to you.
Comments: ________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Signature of Clerk of Court _________________________________________________Date________________
JDF 220 2/05
REQUEST FOR ADMINISTRATIVE REVIEW OF INCOME TAX OFFSET
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