DR 1367 (08/06/14) 
                                         COLORADO DEPARTMENT OF REVENUE
     *141367V219999*                     Denver, CO 80261-0009

                      Affidavit Of Sales Paid By Government
                                               Credit Card
  I affirm that this purchase qualifies for the Colorado        I have checked the applicable boxes below regarding 
sales tax exemption for sales to the United States            information about payment for this purchase.
government, the State of Colorado, its departments              I accept that I remain directly liable for the sales or use 
and institutions, and its political subdivisions (county      tax assessment, and any applicable penalty or interest, 
and local governments, school districts and special           if my purchase is found to not qualify for the exemption.
districts); is a government purchase used only in an 
official governmental capacity; and will be paid directly       I understand that the vendor may request this affidavit 
by a government agency.                                       for every purchase.

Please Print or Type 
Last Name                                     First Name                                 Middle Initial 

Street Address

City                                                                   State             Zip

Driver’s License State and Last 4 Digits      SSN                      FEIN

Agency Name                                                            Agency Phone Number
                                                                       (              )

Check all that apply (For further information visit the Department Of Revenue website at www.TaxColorado.com)

     The agency exemption number is printed on the card. The number is 98 or 098-

     The card is a State/Central Travel Card. The State card has the State seal and the words “Tax Exempt” on it
     The card is a Purchasing Card. The federal version has a picture of the U.S. Capitol. The state card has “Com-
     mercial” or “Purchasing” printed on it.
     The card has an 8 digit exemption number below the cardholders name. The number is
     The card is an Integrated Card (w/picture of the U.S. flag) or a Travel Card(w/picture of an airplane) And the 
     sixth digit of the card is 0,6,7,8, or 9.
     The card is a Department of the Interior Mastercard issued by Bank of America w/acct beginning 5568-16.

     The card is not Bureau of Land Management or National Park Services (Department of Interior).
     The card State Department issued with the name/photo of the bearer and an image of an animal native to North 
     America on the card.
Signature of Customer                                                  Date (MM/DD/YY)