Arizona Form 140 - Resident Personal Income Tax Return Page 2
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1
2
3Your Name (as shown on page 1)
Your Social Security Number
00
37 Enter the amount from page 1, line 36 ........................................................................................................................... 37
00
38 Age 65 or over:
....................................................................................................... 38
Multiply the number in box 8 by $2,100
00
39 Blind:
...................................................................................................................... 39
Multiply the number in box 9 by $1,500
00
40 Dependents:
......................................................................................................... 40
Multiply the number in box 10 by $2,300
00
41 Qualifying parents and grandparents:
..................................................................................... 41
Multiply box 11 by $10,000
00
42 Arizona adjusted gross income:
.................................... 42
Subtract lines 38 through 41 from line 37 and enter the difference
00
I
S
43 Deductions: Check box and enter amount.
........................
ITEMIZED
STANDARD 43
See instructions
43
43
00
44 Personal exemptions:
............................................................................................................................. 44
See instructions
00
45 Arizona taxable income:
................................................... 45
Subtract lines 43 and 44 from line 42. If less than zero, enter zero
00
46 Compute the tax using amount on line 45 and Tax Table X, Y or Optional Tax Tables ................................................... 46
00
47 Tax from recapture of credits from Arizona Form 301, Part 2, line 40 ............................................................................ 47
00
48 Subtotal of tax:
....................................................................................................... 48
Add lines 46 and 47 and enter the total
00
49 Family income tax credit
.......................................................................................... 49
(from the worksheet - see instructions)
00
50 Credits from Arizona Form 301, Part 2, line 76 .............................................................................................................. 50
00
51 Balance of tax:
.................. 51
Subtract lines 49 and 50 from line 48. If the sum of lines 49 and 50 is more than line 48, enter zero
00
52 2016 AZ income tax withheld.......................................................................................................................................... 52
00
00
00
53 2016 AZ estimated tax payments
a
Claim of Right
b
.. 53c
.. 53
53
Add 53a and 53b
00
54 2016 AZ extension payment (Form 204) ........................................................................................................................ 54
00
55 Increased Excise Tax Credit
.................................................................................... 55
(from the worksheet - see instructions)
00
56 Property Tax Credit from Form 140PTC ......................................................................................................................... 56
00
57 Other refundable credits:
1
2
3
349 57
.......................
308-I
342
Check the box(es) and enter the total amount
57
57
57
00
58 Total payments and refundable credits:
................................
58
Add lines 52 through 57 and enter the total
00
59 TAX DUE:
........ 59
If line 51 is larger than line 58, subtract line 58 from line 51 and enter amount of tax due. Skip lines 60, 61 and 62
00
60 OVERPAYMENT:
........................ 60
If line 58 is larger than line 51, subtract line 51 from line 58 and enter amount of overpayment
00
61 Amount of line 60 to be applied to 2017 estimated tax................................................................................................... 61
00
62 Balance of overpayment:
.................................................................... 62
Subtract line 61 from line 60 and enter the difference
Solutions Teams
00
00
63 - 72 Voluntary Gifts to:
64
63
Arizona Wildlife ...............
Assigned to Schools ...........
00
00
00
66
67
65
Domestic Violence Shelter .
Political Gift.....................
Child Abuse Prevention ...........
00
00
00
68
69
70
Neighbors Helping Neighbors..
Special Olympics ................
Veterans’ Donations Fund
Sustainable State Parks
00
00
71
72
I Didn’t Pay Enough Fund........
and Road Fund ...................
73 Political Party
1
2
3
4
(if amount is entered on line 67 - check only one):
Democratic
Green Party
Libertarian
Republican
73
73
73
73
00
74 Estimated payment penalty and Arizona Long-Term Health Care Savings Account (AZLTHSA) penalty ...................... 74
75
1
2
3
4
Annualized/Other
Farmer or Fisherman
Form 221 included
AZLTHSA Penalty
75
75
75
75
00
76 Add lines 63 through 72 and 74; enter the total.............................................................................................................. 76
00
77 REFUND:
.......................................................... 77
Subtract line 76 from line 62. If less than zero, enter amount owed on line 78
A
A
Direct Deposit of Refund: Check box
if your deposit will be ultimately placed in a foreign account; see instructions.
77
77
ROUTING NUMBER
ACCOUNT NUMBER
C
Checking or
98
S
Savings
78 AMOUNT OWED:
Add lines 59 and 76.
Make check payable to Arizona Department of Revenue; write your SSN on payment,
00
................................................................................................................................................. 78
and include with your return
Under penalties of perjury, I declare that I have read this return and any documents with it, and to the best of my knowledge and belief, they are
true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
YOUR SIGNATURE
DATE
OCCUPATION
SPOUSE’S SIGNATURE
DATE
SPOUSE’S OCCUPATION
PAID PREPARER’S SIGNATURE
DATE
FIRM’S NAME (PREPARER’S IF SELF-EMPLOYED)
PAID PREPARER’S STREET ADDRESS
PAID PREPARER’S TIN
(
)
PAID PREPARER’S CITY
STATE
ZIP CODE
PAID PREPARER’S PHONE NUMBER
If you are sending a payment with this return, mail to Arizona Department of Revenue, PO Box 52016, Phoenix, AZ 85072-2016.
Include the payment with Form 140.
If you are expecting a refund or owe no tax, or owe tax but are not sending a payment, mail to Arizona Department of Revenue, PO Box 52138, Phoenix, AZ 85072-2138.
AZ Form 140 (2016)
ADOR 10413 (16)
Page 2 of 3
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