Free GWS-70, Refund Request Form - Colorado

Colorado Division of Water Resources Department of Natural Resources 1313 Sherman Street., Room 821, Denver, CO 80203 phone ­ (303)866-3581 records ­ (303)866-3447 fax: (303)866-2223 www.water.state.co.us
Designated Ground Water Basin requests are not applicable for new appropriations, change of water right and objections, 37-90-116, 10 C.R.S (2003)

Office Use Only Approved_______ Denied_________ Initials_________ Amount________

Form GWS-70

(08/2006)

Refund Request
Name Mailing Address City State

Reason__________________________________ ________________________________________ ________________________________________
Zip Code

________________________________________ ________________________________________ Receipt No.

Telephone Number (w/ Area Code) (REQUIRED)

Give as much detail as possible. Attach additional pages if necessary. Include in your request, your original method and date of payment, and amount paid.

Why is a refund being requested?

_________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
Printed Name Signature Date