Arizona Form 140x - Individual Amended Income Tax Return - 2016 Page 2
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1
2
3Your Name (as shown on page 1)
Your Social Security Number
You must complete Part 1, Dependent Exemptions, for each person included in the number entered on page 1, in box(es) 15 or 16. If you do not
complete Part 1, the exemption(s) may be denied. Do not count or list yourself or your spouse as dependents.
(Box 15): Dependent Information: Children and other dependents. For more space, (check)
and complete page 3.
(a)
(b)
(c)
(d)
(e)
(f)
RELATIONSHIP
NO. OF MONTHS
FIRST AND LAST NAME
SOCIAL SECURITY
if this person
if you did not claim
LIVED IN YOUR
did not qualify as a
this person on your
(Do not list yourself or spouse.)
NO.
dependent on your
federal return due to
HOME IN 2016
federal return
educational credits
15
a
15
b
15
c
(Box 16): Qualifying parents and grandparents. See instructions. For more space, (check)
and complete page 3.
(a)
(b)
(c)
(d)
(e)
(f)
RELATIONSHIP
NO. OF MONTHS
FIRST AND LAST NAME
SOCIAL SECURITY
if
if
LIVED IN YOUR
(Do not list yourself or spouse.)
NO.
age 65 or over
died in 2016
HOME IN 2016
16
a
16
b
INCOME, DEDUCTIONS, CREDITS: In column (a), list the items you are changing. In column (b), enter the amount claimed on your original return or
most recent amended return. In column (c), enter the amount of the change. In column (d), enter the corrected amount for the item you are changing.
(a)
(b)
(c)
(d)
INCOME, DEDUCTIONS, AND CREDITS YOU ARE CHANGING
ORIGINAL AMOUNT
AMOUNT TO
CORRECTED AMOUNT
REPORTED
ADD OR SUBTRACT
$
$
$
53
a
$
$
$
53
b
$
$
$
53
c
NET CAPITAL GAIN OR (LOSS): If you are changing any amount on lines 54a through 54e, complete columns (b), (c), and (d).
(a)
(b)
(c)
(d)
ITEM
ORIGINAL AMOUNT
AMOUNT TO
CORRECTED AMOUNT
REPORTED
ADD OR SUBTRACT
54
Total net capital gain or (loss) reported on
a
$
$
$
Form 140, line 18; Form 140NR, line 32; Form 140PY, line 32 ......................
54
Total net short-term capital gain or (loss) reported on
b
$
$
$
Form 140, line 19; Form 140NR, line 33; Form 140PY, line 33 ......................
54
Total net long-term capital gain or (loss) reported on
c
$
$
$
Form 140, line 20; Form 140NR, line 34; Form 140PY, line 34 ......................
54
Net long-term capital gains from assets acquired after December 31, 2011
d
$
$
$
reported on Form 140, line 21; Form 140NR, line 35; Form 140PY, line 35 ...
54
Amount of allowable subtraction reported on Form 140, line 22;
e
$
$
$
Form 140NR, line 36; Form 140PY, line 36 ....................................................
55 REASON FOR THE CHANGE: Give the reason for each change listed in Part 2:
If your address is the same on this amended return as it was on your original return, write “same” on the line below.
56
Name
56
Number and Street, R.R.
Apt. No.
a
b
56
City, Town or Post Office
State
ZIP Code
c
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 140X. Make check payable to Arizona Department of Revenue; write your SSN on payment.
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.
Form 140X (2016)
Page 2 of 3
ADOR 10573 (16)
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