Arizona Form 140x - Individual Amended Income Tax Return - 2016 Page 3
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1
2
3Your Name (as shown on page 1)
Your Social Security Number
Dependent Information - Continuation Sheet
from Page 2, Part 1, Dependents
Complete this form only if you need additional space from page 2, Part 1 to list dependents or qualifying parents or grandparents.
Children and other dependents, continued from page 2, Part 1.
(a)
(b)
(c)
(d)
(e)
(f)
RELATIONSHIP
NO. OF MONTHS
FIRST AND LAST NAME
SOCIAL SECURITY NO.
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.)
dependent on your
federal return due to
HOME IN 2016
federal return
educational credits
15
d
15
e
15
f
15
g
15
h
15
i
15
j
15
k
15
l
15
m
15
n
15
o
15
p
15
q
15
r
15
s
15
t
15
u
Qualifying parents and grandparents, continued from page 2, Part 1.
(a)
(b)
(c)
(d)
(e)
(f)
FIRST AND LAST NAME
SOCIAL SECURITY NO.
RELATIONSHIP
NO. OF MONTHS
if
if
LIVED IN YOUR
(Do not list yourself or spouse.)
age 65 or over
died in 2016
HOME IN 2016
16
c
16
d
16
e
16
f
16
g
16
h
16
i
16
j
Print Page 3
Form 140X (2016)
Page 3 of 3
ADOR 10573 (16)
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