"Fee Waiver and Tax-Exempt Status Form" - Colorado

Fee Waiver and Tax-Exempt Status Form is a legal document that was released by the Colorado Department of Public Health and Environment - a government authority operating within Colorado.

Form Details:

  • Released on March 1, 2016;
  • The latest edition currently provided by the Colorado Department of Public Health and Environment;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Public Health and Environment.

ADVERTISEMENT
ADVERTISEMENT

Download "Fee Waiver and Tax-Exempt Status Form" - Colorado

146 times
Rate (4.3 / 5) 10 votes
FW
Fee Waiver and Tax-exempt Status
Tax-exempt status allows patients to:
1. Apply for a medical marijuana card without paying the application fee.
2. Purchase medical marijuana without paying Colorado sales taxes.
You may qualify for a fee waiver if your household income is 185% of the Federal Poverty Level* or less. The
chart below indicates the annual adjusted household incomes that qualify.
# in Family
Annual Household Income
1
$21,775
2
$29,471
3
$37,167
4
$44,863
5
$52,559
6
$60,255
7
$67,951
8
$75,647
Each additional family member
$7,696
*Poverty guidelines are updated periodically in the Federal Register by the U.S. Department of Health and
Human Services under the authority of 42 U.S.C. 9902(2).
4300 Cherry Creek Dr S, HSV-8630, Denver, CO 80246 | P 303-692-2184 | F 303-758-5182
medical.marijuana@state.co.us
|
www.colorado.gov/cdphe/medicalmarijuana
MMR1005 Fee Waiver | Revised March 2016
FW
Fee Waiver and Tax-exempt Status
Tax-exempt status allows patients to:
1. Apply for a medical marijuana card without paying the application fee.
2. Purchase medical marijuana without paying Colorado sales taxes.
You may qualify for a fee waiver if your household income is 185% of the Federal Poverty Level* or less. The
chart below indicates the annual adjusted household incomes that qualify.
# in Family
Annual Household Income
1
$21,775
2
$29,471
3
$37,167
4
$44,863
5
$52,559
6
$60,255
7
$67,951
8
$75,647
Each additional family member
$7,696
*Poverty guidelines are updated periodically in the Federal Register by the U.S. Department of Health and
Human Services under the authority of 42 U.S.C. 9902(2).
4300 Cherry Creek Dr S, HSV-8630, Denver, CO 80246 | P 303-692-2184 | F 303-758-5182
medical.marijuana@state.co.us
|
www.colorado.gov/cdphe/medicalmarijuana
MMR1005 Fee Waiver | Revised March 2016
FW
Fee Waiver and Tax-Exempt Status
This form must be submitted with a certified copy of your Colorado Tax Return
Patient Information
STAFF
1. Last Name
2. First Name
ONLY
3. Middle Initial
4. Date of Birth
________
Evaluated
5a. Mailing Address
5b. Apt/Ste #
6. City
State
7. Zip Code
8. County
CO
9. Telephone
10. Email
11. List all the people in the household who were listed on your Colorado tax return.
Last Name
First Name
Date of Birth
Relationship to Patient
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
I hereby certify that I, the patient, have verified the above information to be accurate and complete and no one other
than me (or my legally authorized representative) is submitting this request on my behalf.
Signature Date
12a. Patient’s or Authorized Representative’s Signature:
12b.
MMR1005 Fee Waiver | March 2016
_______
QA
Page of 2