Arizona Form 140et - Credit For Increased Excise Taxes - 2016
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1
2Arizona Form
FOR CALENDAR YEAR
Credit for Increased Excise Taxes
2016
140ET
Check box 82F if filing under extension
Check box 95 if amending credit for tax year 2016
82F
95
Your First Name and Middle Initial
Last Name
Your Social Security Number
Enter
1
your
Spouse’s First Name and Middle Initial (if box 4 or 6 checked)
Last Name
Spouse’s Social Security No.
SSN(s).
1
Current Home Address - number and street, rural route
Apt. No.
Daytime Phone (with area code)
2
94
City, Town or Post Office
State
ZIP Code
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
88
3
FILING STATUS (check the appropriate box):
4
Married filing joint claim
5
Head of household:
Enter name of qualifying child or dependent on next line:
81 PM
80 RCVD
6
Married filing separate claim:
Enter spouse’s name and Social Security Number above.
7
Single
Note: If you are married and you qualify to claim this credit, you must file a married filing separate
claim if your spouse was sentenced for at least 60 days during 2016 to a county, state or federal prison.
8 I have read “Who Can File Form 140ET” on page 2, and I certify that I qualify to claim this credit on this form .. 8
YES
NO
Note: If you checked “No”, STOP. DO NOT file Form 140ET.
9 List dependents (
). If married filing a joint claim, you may list up to 2 dependents;
see instructions on page 3
all others may list up to 3.
SOCIAL SECURITY NUMBER
FIRST NAME
LAST NAME
OR ITIN
A1
9
A2
9
A3
9
10 Total number of dependents entered on lines
A1 through
A3 .................................................................... 10
9
9
11 If you checked box 4, enter the number “2” here. If you checked box 5, 6, or 7, enter the number “1” here . 11
12 Add the amount on line 10 and line 11. Enter the total ................................................................................. 12
13 Multiply the amount on line 12 by $25. Enter the result................................................................................ 13
00
14 Enter the smaller of line 13 or $100............................................................................................................... 14
00
A
A
Direct Deposit of Refund: Check box
if your deposit will be ultimately placed in a foreign account; see instructions.
14
14
ROUTING NUMBER
ACCOUNT NUMBER
C
Checking or
98
S
Savings
If this is your first claim for 2016, STOP HERE, AND GO TO THE SIGNATURE BOX BELOW.
If this is an amended claim, complete lines 15 through 17, and check box 95 at the top of the form.
AMENDED
00
15 Enter the amount from line 5 of the worksheet on page 4 of the instructions ............................................... 15
00
16 Additional refund: If line 14 is larger than line 15, subtract line 15 from line 14 ........................................... 16
00
17 Amount to pay: If line 14 is less than line 15, subtract line 14 from line 15 .................................................. 17
Make check payable to Arizona Department of Revenue; write your SSN on payment, and include with Form 140ET.
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 (PAID 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 this claim to: Arizona Department of Revenue, PO Box 52138, Phoenix, AZ 85072-2138.
ADOR 10532 (16)
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