Arizona Form 140 - Resident Personal Income Tax Return 2011 (Page 2 of 2) in pdf

Your Name (as shown on page 1)

Your Social Security No.

PART A: Dependents, Qualifying Parents and Grandparents -

do not list yourself or spouse

If completing Part A, also complete Part C, lines C15 and/or C16 and C17.

A1 List children and other dependents. If more space is needed, attach a separate sheet.

NO. OF MONTHS LIVED

FIRST AND LAST NAME

SOCIAL SECURITY NO.

RELATIONSHIP

IN YOUR HOME IN 2011

A2 Enter total number of persons listed in A1 here and on the front of this form, box 10;

. .... TOTAL

also complete Part C below

A3 a Enter the names of the dependents listed above who do not qualify as your dependent on your federal return:

b Enter dependents listed above who were not claimed on your federal return due to education credits:

A4 List qualifying parents and grandparents. If more space is needed, attach a separate sheet.

You cannot list the same person here and also on line A1. For information on who is a

qualifying parent or grandparent, see page 6 of the instructions.

NO. OF MONTHS LIVED

FIRST AND LAST NAME

SOCIAL SECURITY NO.

RELATIONSHIP

IN YOUR HOME IN 2011

A5 Enter total number of persons listed in A4 here and on the front of this form, box 11 ................................................ TOTAL

PART B: Additions to Income

B6 Non-Arizona municipal interest ...........................................................................................................................................

B7 Ordinary income portion of lump-sum distributions excluded on your federal return ..........................................................

B8 Total federal depreciation.

..............................................................................................

Also see the instructions for line C22

B9 Medical savings account (MSA) distributions.

.........................................................................

See page 7 of the instructions

B10 I.R.C. §179 expense in excess of allowable amount.

....................................................

B10

Also see the instructions for line C26

B11 Other additions to income.

...............................................................................

B11

See instructions and attach your own schedule

..........................................................................

B12 Total:

Add lines B6 through B11. Enter here and on the front of this form, line 13

B12

PART C: Subtractions from Income

C13 Exemption: Age 65 or over.

.........................................

C13

Multiply the number in box 8, page 1, by $2,100

C14 Exemption: Blind.

.........................................................

Multiply the number in box 9, page 1, by $1,500

C14

C15 Exemption: Dependents.

...........................................

C15

Multiply the number in box 10, page 1, by $2,300

C16 Exemption: Qualifying parents and grandparents.

Multiply the number in

......................................................................................................................

box 11, page 1, by $10,000

C16

C17 Total exemptions: Add lines C13 through C16. If you have no other subtractions from

income, skip lines C18 through C30 and enter the amount on line C17 on Form 140, Page 1, line 14 .....................

C17

C18 Interest on U.S. obligations such as U.S. savings bonds and treasury bills ........................................................................

C18

C19 Exclusion for federal, Arizona state or local government pensions (up to $2,500 per taxpayer) .........................................

C19

C20 Arizona state lottery winnings included as income on your federal return (up to $5,000 only) ...........................................

C20

C21 U.S. Social Security or Railroad Retirement Act benefits included as income on your federal return

...

C21

(the taxable amount)

C22 Recalculated Arizona depreciation ......................................................................................................................................

C22

C23 Certain wages of American Indians .....................................................................................................................................

C23

C24 Income tax refund from other states.

..........................................................................................................

C24

See instructions

C25 Deposits and employer contributions into MSAs.

...................................................................

C25

See page 11 of the instructions

C26 Adjustment for I.R.C. §179 expense not allowed ...............................................................................................................

C26

C27 Pay received for active service as a member of the reserves, national guard or the U.S. armed forces ............................

C27

C28 Net operating loss adjustment.

...................................................................

C28

See instructions before you enter any amount here

C29 Other subtractions from income.

......................................................................

C29

See instructions and attach your own schedule

C30 Total: Add lines C17 through C29. Enter here and on the front of this form, line 14...................................................

C30

Part D: Last Name(s) Used in Prior Years

– if different from name(s) used in current year

D31

I have read this return and any attachments with it. Under penalties of perjury, I declare that 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 TIN

PAID PREPARER’S ADDRESS

PAID PREPARER’S PHONE NO.

If you are also sending a payment, mail to Arizona Department of Revenue, PO Box 52016, Phoenix, AZ 85072-2016 (PO Box 29204, Phoenix, AZ 85038-9204 if your return has a barcode).

If you are not sending a payment, mail to Arizona Department of Revenue, PO Box 52138, Phoenix, AZ 85072-2138 (PO Box 29205, Phoenix, AZ 85038-9205 if your return has a barcode).

AZ Form 140 (2011)

ADOR 10413 (11)

Page 2 of 2

Arizona Form 140 - Resident Personal Income Tax Return 2011 Page 2

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