DR 1101 (08/12/20)
                                                COLORADO DEPARTMENT OF REVENUE
                                                Tax.Colorado.gov
*DO=NOT=SEND*

Annual Reconciliation of Income Tax Withheld on Gaming Winnings
                                                Instructions
If  you  are  filing  an  amended  return,  check  the  amended  Compute the interest due at the statutory rate printed in FYI 
return box. A separate amended return must be filed for each  General 11 at Tax.Colorado.gov
period. The amended return must show all tax columns as         If there is an overpayment, put the amount of line 3B. 
corrected, not the difference(s). The amended return will       You must apply for a refund of the overpayment of tax 
replace the original return in its entirety.                    by filing DR 0137. This form may be obtained online at 
Use this form to reconcile the amount of backup withholding     Tax.Colorado.gov
remitted with the total reported on Forms W-2G.                 Send the W-2G form(s) along with this form for the 
If additional tax is due, put the amount on line 3A. Compute  applicable period.
penalty at the larger of 5% (.05) of the balance due for the 
                                                                Mail them to:
first month you are late and 1/2% (.005) additional penalty for 
each additional month you are late. The maximum penalty         Colorado Department of Revenue 
is 12% (.12), and the minimum penalty is $5.00.                 Denver CO 80261-0009

                                                   DR 1101 (08/12/20)
                                                   COLORADO DEPARTMENT OF REVENUE
                                                   Tax.Colorado.gov
*201101==19999*                                    Page 1 of 1

                              Annual Reconciliation of Income Tax  
                                    Withheld on Gaming Winnings
                                                                                                             1010-130

Check here if this is an Amended Return 

Last Name or Business Name                                             First Name                            Middle Initial

Street Address

City                                                                                   State      ZIP

Account Number              Period (MM/YY - MM/YY) Due Date (MM/DD/YY) SSN 1           SSN 2             FEIN
                                   –

1. Total Colorado income tax withheld per W-2Gs

2. Total Colorado income taxes withheld and remitted for calendar year indicated. 
                                                                                             (100)

3.  A. Additional Tax Due   or
                                                                                             (905)

   B. Tax Overpayment (See instructions)
                                                                                             (200)

4. Penalty (see instructions) 
                                                                                             (300)

5. Interest (see instructions) 
                                                                                             (355)

6. Amount Owed 
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 Department of Revenue may collect the payment amount directly from your 
bank account electronically.
                            Mail reconciliation with W-2G forms and any payment due on line 6 to:
                                   Colorado Department of Revenue, Denver, CO 80261-0009
Signed under penalty of perjury in the second degree.
Signature                                                              Date (MM/DD/YY)       Phone Number