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Fill and Sign the Request for Administrative Review of Income Tax Offset Form

Fill and Sign the Request for Administrative Review of Income Tax Offset Form

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JDF 220 2/05 REQUEST FOR ADMINISTRATIVE REVIEW OF INCOME TAX OFFSETCounty Court District Court __________________________County, ColoradoCourt Address: People of the State of Colorado v. Defendant: _________________________________Social Security Number: _______________________________Email Address: ______________________________________ COURT USE ONLY Case Number:_______________________________ REQUEST FOR ADMINISTRATIVE REVIEW OF INCOME TAX OFFSET 1.I have received a notice from the Department of Revenue, State of Colorado, informing me that my state income tax return, or a portion thereof, has been offset for payment of court-ordered fines, costs and/or restitution, in accordance with §§16-11-101.8 and 16-18.5-106.8, C.R.S. A copy of the notice is attached.2. I hereby request an administrative review of this income tax offset for the following reason (select one box below; a brief comment may be included): I am not required to pay fines, costs and/or restitution to this court. _____________________________________________________________________________________ _____________________________________________________________________________________ The amount of fines, costs and/or restitution owed to the court is not correct. _____________________________________________________________________________________ _____________________________________________________________________________________ Other: _______________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________3.This request is made within thirty (30) days from the date I received the notice of income tax offset from the Department of Revenue.Date: ______________________________ _____________________________________ Signature ______________________________________Address______________________________________City State Zip Code______________________________________Home Phone # Cell # COURT USE ONLY As a result of an administrative review of your tax offset: It has been determined that the tax offset was appropriate. The amount owed is $___________. A copy of the court’s case financial record is attached. It has been determined that you are owed a refund. A refund in the amount of $ ________ will be sent to you.Comments: __________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________Signature of Clerk of Court _________________________________________________Date________________

Valuable instructions for completing your ‘Request For Administrative Review Of Income Tax Offset’ online

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  2. Click +Create to upload a document from your device, cloud storage, or our template library.
  3. Open your ‘Request For Administrative Review Of Income Tax Offset’ in the editor.
  4. Click Me (Fill Out Now) to set up the form on your end.
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The best way to complete and sign your request for administrative review of income tax offset form

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