DR 0366 (06/14/21) 
                                                         COLORADO DEPARTMENT OF REVENUE
                                                         Tax.Colorado.gov
*220366==19999*                                          Page 1 of 1

                      2022 Rural & Frontier                                             Tax Year             SSN or ITIN

                  Health Care Preceptor Credit
Preceptor’s Last Name                                    Preceptor’s First Name                                         Middle Initial

Preceptor’s Email                                                   Preceptor’s Phone

Credentials

Colorado License Type

       Doctor of Medicine  Doctor of Osteopathic Medicine                   Advance Practice Nurse

       Physician Assistant Doctor of Dental Surgery                         Doctor of Dental Medicine

License Number

Name of Preceptor’s Practice and Location

Address

City                                                     County                                              State ZIP

Only 200 primary health care preceptors are entitled to claim this credit each tax year. In order to claim this credit, the preceptor must:
i.  Receive certification that the preceptor satisfied all requirements to receive the credit from the institution for which the 
     preceptor teaches, whether it is an institution of higher education or a hospital, clinic, or other medical facility, or from 
     the regional AHEC office with jurisdiction over the area in which the preceptorship took place.
ii.  Send an electronic copy of the completed certification to the Department by email to dor_preceptor@state.co.us.
iii.  If the preceptor receives notification from the Department that the credit has been issued to him or her, file a Colorado 
     income tax return and claim the credit on his or her return.
If applicable, Colorado AHEC Location  

Students Preceptored – Include Name, School, Program Name, Dates of Clinical Rotation, Dates of Preceptorship

By executing this form, I certify that during the income tax year the taxpayer satisfied all requirements to receive the credit.
     Signature of Person Authorized to Certify the Credit