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Colorado Medical Savings Account - Employee Election
Extracted from PDF file 2023-colorado-form-dr-0810.pdf, last modified August 2013Medical Savings Account - Employee Election
DR 0810 (07/18/13) COLORADO DEPARTMENT OF REVENUE Denver, CO 80261-0005 *130810==19999* Employees Election Regarding Medical Savings Account Employee's Last Name First Name Middle Initial SSN Employer's Name Employer's Address City State Zip Account Administrator's Last Name First Name Middle Initial Account Administrator's Address City State Zip I hereby certify that I am an employee of the above listed employer who has offered to establish a medical savings account in my name with the above listed account administrator in accordance with §39-22-504.7, C.R.S.; or that my employer has not offered to establish such an account but I have established such an account with the above listed account administrator. I hereby elect to have my contributions to such account, not to exceed $3,000 in any one calendar year, whether paid by my employer, withheld from my wages and paid to the account administrator by my employer, or paid directly to the account administrator by myself, to be made on a Colorado pre-tax basis. Amounts may be distributed from a medical savings account only for the purpose of: reimbursing the eligible medical expenses of the account holder, his or her spouse or dependent children; cashing out the balance in the account of a deceased holder; or cashing out an account holder's prior years' balance. This election and agreement shall continue in effect until canceled by myself or by the account administrator. I hereby acknowledge that I understand that any amounts withdrawn from my account for any purpose other than the payment of medical expenses of myself, my spouse, or my dependent children will constitute Colorado taxable income for myself or my estate, as the case may be. Signature Date (MM/DD/YY)
Form DR 0810
More about the Colorado Form DR 0810 Individual Income Tax TY 2023
This form is to certify that you are an employee of the above listed employer who has offered to establish a medical savings account in my name with the above listed account administrator in accordance with ยง39-22-504.7, C.R.S.; or that your employer has not offered to establish such an account but I have established such an account with the above listed account administrator.
We last updated the Medical Savings Account - Employee Election in February 2024, so this is the latest version of Form DR 0810, fully updated for tax year 2023. You can download or print current or past-year PDFs of Form DR 0810 directly from TaxFormFinder. You can print other Colorado tax forms here.
Other Colorado Individual Income Tax Forms:
TaxFormFinder has an additional 64 Colorado income tax forms that you may need, plus all federal income tax forms.
| Form Code | Form Name |
|---|---|
| Form 104 | Colorado Income Tax Return |
| Form 104EP | Individual Estimated Income Tax Payment Form |
| Form 104CR | Tax Credits for Individuals |
| Form DR 0900 | Payment Voucher for Individuals |
| Form 104X | Amended Income Tax Return Form |
View all 65 Colorado Income Tax Forms
Form Sources:
Colorado usually releases forms for the current tax year between January and April. We last updated Colorado Form DR 0810 from the Department of Revenue in February 2024.
About the Individual Income Tax
The IRS and most states collect a personal income tax, which is paid throughout the year via tax withholding or estimated income tax payments.
Most taxpayers are required to file a yearly income tax return in April to both the Internal Revenue Service and their state's revenue department, which will result in either a tax refund of excess withheld income or a tax payment if the withholding does not cover the taxpayer's entire liability. Every taxpayer's situation is different - please consult a CPA or licensed tax preparer to ensure that you are filing the correct tax forms!
Historical Past-Year Versions of Colorado Form DR 0810
We have a total of thirteen past-year versions of Form DR 0810 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:
2011 Form DR 0810
DR 0810 WEB
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