DR 1091 (08/12/20)
                                              COLORADO DEPARTMENT OF REVENUE
                                              Tax.Colorado.gov
*DO=NOT=SEND*

                           Backup Withholding Tax Return - Gaming
                                                  Instructions
Line 1:   Enter the total state tax withheld on line 14 of all How to file a return:
       federal forms W-2G.                                     This return, together with remittance by check, draft or 
Line 2:   Enter the total state income tax withheld from non-  money order made payable to the Colorado Department of 
       resident aliens on line 12 of federal form 1042S.       Revenue, must be filed with the 
Line 3:  Enter the total of lines 1 and 2.                      Colorado Department of Revenue
                                                                Denver, CO 80261-0009
Lines 
4 & 5:   Failure to file the return and pay the tax on time    on or before the 15th day of the month following the close of 
       subjects the vendor to a penalty of 5% + 1/2%           the taxable period. Mailed returns must be postmarked the 
       per month with the maximum being 12% or a               15th day of the month or prior thereto.
       minimum of $5.00. Interest is due at the current 
                                                               If you are filing an amended return you are required to 
       statutory rate.
                                                               mark the Amended Return box. A separate amended 
Line 6:  Enter the total of lines 3, 4 and 5.                  return must be filed for each period. The amended return 
Line 7:  If an underpayment of tax was made on a               must show all tax columns as corrected, not merely the 
       previous return, enter the amount of                    difference(s). The amended return will replace the original 
       underpayment plus penalty and interest line 7.          return in its entirety.

Line 8:   If an overpayment of tax was made on a               How to remit W-2G Forms:  
       previous return, enter the amount of the 
                                                               The Colorado copies of the W-2G forms can be filed on 
       overpayment on line 8. Overpayment must not 
                                                               Revenue Online at www.Colorado.gov/RevenueOnline 
       result in a negative balance.
                                                               If you are submitting paper W-2Gs, you must complete 
Line 9:   Enter the total amount due (line 6 plus line 7 or    and attach a DR 1091. Forms can be remitted as often as 
       minus line 8).                                          monthly but have to be remitted annually at a minimum.

                                               DR 1091 (08/12/20)
                                               COLORADO DEPARTMENT OF REVENUE
                                               Tax.Colorado.gov
*DO=NOT=SEND*

                        Backup Withholding Tax Return - Gaming
                                          Instructions (continued)

                                When to withhold income tax on winnings  
                        from slot machines, bingo and horse and dog racing:
Slot Machines and Bingo Winnings                            Horse and Dog Racing Winnings
Is the amount $1,200 or more?                               Is the amount greater than $5,000 and at least 300 times 
       If no:  No withholding is required                   the wagered amount?
       If yes: Continue to following question                      If no:  No withholding is required
Has proper identification been provided to the operation by        If yes: Continue to following question
the customer?                                               Is the customer a non-resident alien?
       If yes: No withholding is required                          If yes: Withhold 4% of gross winnings for 
       If no:  Continue to following questions                             Colorado on form 1042S
Is the customer a non-resident alien?                              If no:  Withhold 4% of gross winnings for 
       If yes: Withhold 4% of gross winnings for                           Colorado on form W-2G
               Colorado on form 1042S
       If no:  Withhold 4% of gross winnings for 
               Colorado on form W-2G

 Line 7.   Enter any payment(s) for prior period(s)         Line 8.   Enter any overpayment(s) for prior period(s) 
          of current year only.                                       of current year only.

 Period Adjusted                                            Period Adjusted

 As filed                                                   As filed
                        $                                                                  $
 As corrected                                               As corrected
                        $                                                                  $
 Difference                                                 Difference (Enter on line 8)
                        $                                                                  $
 Penalty
                        $
 Interest
                        $
 Total (Enter on line 7)
                        $

                                                    DR 1091 (08/12/20)
                                                    COLORADO DEPARTMENT OF REVENUE                                                                                         
                                                    Tax.Colorado.gov
*201091==19999*                                     Page 1 of 1

                     Backup Withholding Tax Return – Gaming 
               Includes slot machines, bingo, and horse and dog racing                                     1010-100
Account Number                     FEIN                             SSN 1                         SSN 2

Period (MM/YY-MM/YY)                                           Due Date (MM/DD/YY)

Last Name or Business Name                                                First Name                       Middle Initial

Address

City                                                                                              State Zip

Signed under penalty of perjury in the second degree. 
Signature                                                                         Date (MM/DD/YY)       Phone Number

Check here if this is an amended return         

1. Resident Income tax withheld Line 14-12G

2. Non-resident income tax withheld Line 12-04S
                                                                                                  (100)

3. Total of lines 1 and 2 
                                                                                                  (200)

4. Penalty 
                                                                                                  (300)

5. Interest 

6. Total of lines 3, 4 & 5
                                                                                                  (900)

7. Additional tax, penalty & interest due for prior periods of current year only. 
                                                                                                  (905)
8.  Overpayment of tax for prior tax periods of current year to be subtracted from 
   current tax.
                                                                                                  (355)

9. Amount Owed (line 6 plus line 7 or minus line 8) 
The state may convert your check to a one-time electronic banking transaction. Your bank account may be debited as early as the same day received by the State. If 
converted, your check will not be returned. If your check is rejected due to insufficient or uncollected funds, the Departments of Revenue may collect the payment amount 
directly from your bank account electronically. 
                            Mail this return with W-2G forms and any payment due on line 9 to:
                            Colorado Department of Revenue, Denver, CO 80261-0009