Arizona Form 140ptc - Property Tax Refund (Credit) Claim - 2016 Page 2
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1
2Your Name (as shown on page 1)
Your Social Security Number
(1)
(2)
(3)
(4)
Part 1
Schedule of Household Income
YOU
YOUR SPOUSE
OTHER PERSONS
TOTAL (1+2+3)
A Salaries, wages, tips, etc., received in 2016 ............................................ A
B Dividend and interest income received in 2016 ....................................... B
C Business and farm income ....................................................................... C
D Gain or loss from sale or exchange of property ....................................... D
E Pension and annuity income. Include Arizona state and local
retirement benefits, civil service, and military retirement. Do
not include social security or railroad retirement benefits ........................ E
F Rent and royalty income .......................................................................... F
G S corporation, partnership, estate, and trust income ............................... G
H Alimony .................................................................................................... H
I Other Income: Specify source on separate sheet ................................... I
J Total household income: Add lines A through I in column (4). Enter here and on the front of this form, line 10 ........................... J
Use the amount on line J, column 4, to compute your credit from the proper schedule below.
2016 Schedule 1
2016 Schedule 2
If you live alone, use this Schedule.
If you live with your spouse or another person, use this Schedule.
Household
Tax
Household
Tax
Household
Tax
Household
Tax
Income
Credit
Income
Credit
Income
Credit
Income
Credit
$
0 - 1,750
$502
$ 2,751 - 2,850
$256
$
0 - 2,500
$502
$ 4,001 - 4,150
$256
1,751 - 1,850
479
2,851 - 2,950
234
2,501 - 2,650
479
4,151 - 4,300
234
1,851 - 1,950
457
2,951 - 3,050
212
2,651 - 2,800
457
4,301 - 4,450
212
1,951 - 2,050
435
3,051 - 3,150
189
2,801 - 2,950
435
4,451 - 4,600
189
2,051 - 2,150
412
3,151 - 3,250
167
2,951 - 3,100
412
4,601 - 4,750
167
2,151 - 2,250
390
3,251 - 3,350
145
3,101 - 3,250
390
4,751 - 4,900
145
2,251 - 2,350
368
3,351 - 3,450
123
3,251 - 3,400
368
4,901 - 5,050
123
2,351 - 2,450
345
3,451 - 3,550
100
3,401 - 3,550
345
5,051 - 5,200
100
2,451 - 2,550
323
3,551 - 3,650
78
3,551 - 3,700
323
5,201 - 5,350
78
2,551 - 2,650
301
3,651 - 3,750
56
3,701 - 3,850
301
5,351 - 5,500
56
2,651 - 2,750
279
3,751 and up
0
3,851 - 4,000
279
5,501 and up
0
Enter the amount of credit on the front of this form, line 11.
Part 2
Credit for Increased Excise Taxes
Do not complete Part 2 if you completed line 16 on page 1 of Form 140PTC. Do not complete Part 2 if you were sentenced for at least 60 days of 2016 to
a county, state, or federal prison. Note: If you are filing a joint Property Tax Credit claim with your spouse, and you are also claiming the Excise tax credit
on Form 140PTC, you cannot claim the Excise Tax Credit for your spouse if your spouse was sentenced for at least 60 days during 2016 to a county, state
or federal prison.
1 List dependents. See page 4 of the instructions.
(a)
(b)
(c)
(d)
FIRST AND LAST NAME
SOCIAL SECURITY NO.
RELATIONSHIP
NO. OF MONTHS LIVED
IN YOUR HOME IN 2016
(Do not list yourself or spouse.)
1a
1b
1c
2 Enter total number of dependents listed on lines 1a through 1c. Also, enter this amount on Form 140PTC, page 1, line 18 ...... 2
3
If you are married filing a joint claim, enter the number “2” here. Otherwise, enter the number “1” ............................................... 3
4
Add the amount on line 2 and line 3, and enter the total .................................................................................................................. 4
00
5
Multiply the amount on line 4 by $25, and enter the result ............................................................................................................... 5
00
6 Enter the smaller of line 5 or $100. Also, enter this amount on Form 140PTC, page 1, line 17 .................................................... 6
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
Mail to Arizona Department of Revenue, PO Box 52138, Phoenix, AZ 85072-2138
AZ Form 140PTC (2016)
Page 2 of 2
ADOR 10567 (16)
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