County Court District Court __________________________County, Colorado Court 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 Home Phone # State Cell # Zip Code ______________________________________ 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________________ JDF 220 2/05 REQUEST FOR ADMINISTRATIVE REVIEW OF INCOME TAX OFFSET American LegalNet, Inc. www.USCourtForms.com