DR 0084 (08/30/13) 
COLORADO DEPARTMENT OF REVENUE                                                                       *130084==19999*
Denver, CO 80261-0005

                                       Substitute Colorado W-2 Form

                                               See Form Below

                                               Photocopy for your records. 
DR 0084 (08/30/13)
Employer’s name, address and ZIP Code:                                                                            State of Colorado 
                                                                 SUBSTITUTE COLORADO W-2 FORM                     Department of Revenue
                                                                      FOR INCOME TAX WITHHELD                     Denver, CO 80261-0005
                                                               Federal Employer’s Identification No. Employer’s Colorado Identification No.
                                                                ●
Employee’s Social Security No.                                                     DATES OF EMPLOYMENT
                                                                            FROM                                  TO
Employee’s name (first, middle, last):                           Month (MM)        Year (YYYY)       Month (MM)         Year (YYYY)

Employee’s address and ZIP Code:                                 COLO. INCOME TAX  FEDERAL INCOME TAX WITH-       TOTAL WAGES
                                                                 WITHHELD,  if any                   HELD, if any (before payroll deductions)
                                                                ●
NOTE: If taxpayer was employed by more than one employer, a separate statement covering each employment and the amount of tax withheld must be filed.
How did you determine the amounts listed above?

Give reason why Form W-2, or the Statement of Corrected Income and Tax Amounts was not furnished by your employer (or the payer), if 
known. Explain your efforts to obtain the required information.

I declare, under penalty of perjury in the second degree, that the statements made herein are true to the best of my knowledge and belief.
Signature:                                                                                                        Date: (MM/DD/YY)