Az Form 140 Py - Part-Year Resident Personal Income Tax Return 2001 Page 2
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1
2Form 140PY (2001) Page 2
ADOR 91-0069 (01) slw
A1
List children and other dependents. Do not list yourself or spouse. 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 2001
A2
Enter total number of persons listed in A1 here and on the front of this form, box 10 .................................................... TOTAL
A2
A3
Enter the names of the dependents age 65 or over listed above who do not qualify as your dependent on your federal return:
A4
List qualifying parents and ancestors of your parents. 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 ancestor of your parents, see page 5 of the instructions.
NO. OF MONTHS LIVED
FIRST AND LAST NAME
SOCIAL SECURITY NO.
RELATIONSHIP
IN YOUR HOME IN 2001
A5
Enter total number of persons listed in A4 here and on the front of this form, box 11. ................................................... TOTAL
A5
/
/
/
/
B6
Dates of Arizona residency: From _____________________ to _____________________.
2001 FEDERAL
2001 ARIZONA
M M
D D
Y Y Y Y
M M
D D
Y Y Y Y
Amount from federal return
Amount only
List other state(s) of residency: ________________________________________________
B7
Wages, salaries, tips, etc. ..................................................................................................................
B7
00
00
B8
Interest ................................................................................................................................................
B8
00
00
B9
Dividends ............................................................................................................................................
B9
00
00
B10
Arizona income tax refunds ................................................................................................................ B10
00
00
B11
Alimony received................................................................................................................................. B11
00
00
B12
Business income (or loss) from federal Schedule C ........................................................................... B12
00
00
B13
Gains (or losses) from federal Schedule D ......................................................................................... B13
00
00
B14
Rents, royalties, partnerships, estates, trusts, small business corporations from federal Schedule E B14
00
00
B15
Other income reported on your federal return..................................................................................... B15
00
00
B16
Total income: Add lines B7 through B15.......................................................................................... B16
00
00
B17
Total IRA deduction ............................................................................................................................. B17
00
00
B18
Other federal adjustments. Attach your own schedule ...................................................................... B18
00
00
B19
Total adjustments: Add lines B17 and B18 ..................................................................................... B19
00
00
B20
Federal adjusted gross income. Subtract line B19 from line B16 in the FEDERAL column .............. B20
00
B21
Arizona income: Subtract line B19 from line B16 in the ARIZONA column. Enter here and on the front of this form, line 15 .
B21
00
B22
Arizona percentage: Divide line B21 by line B20, and enter the result (not over 100%) ..........................................................
B22
%
C23
Early withdrawal of Arizona Retirement System contributions...................................................................................................
C23
00
C24
Other additions to income. See instructions and attach your own schedule.............................................................................
C24
00
C25
Total: Add lines C23 and C24. Enter here and on the front of this form on line 16 ..................................................................
C25
00
D26
Exemption: Age 65 or over. Multiply the number in box 8, page 1, by $2,100 .................................. D26
00
D27
Exemption: Blind. Multiply the number in box 9, page 1, by $1,500 ................................................. D27
00
D28
Exemption: Dependents. Multiply the number in box 10, page 1, by $2,300.................................... D28
00
D29
Exemption: Qualifying parents and ancestors. Multiply the number in box 11, page 1, by $10,000. D29
00
D30
Total exemptions: Add lines D26 through D29................................................................................... D30
00
D31
Multiply line D30 by the percentage on line B22, and enter the result.......................................................................................
D31
00
D32
Interest on U.S. obligations such as U.S. savings bonds and treasury bills included in the ARIZONA column.........................
D32
00
D33
Arizona state lottery winnings included on line B15 in the ARIZONA column (up to $5,000 only).............................................
D33
00
D34
U.S. Social Security or Railroad Retirement Act benefi ts included in your ARIZONA income ...................................................
D34
00
D35
Other subtractions from income. See instructions and attach your own schedule ...................................................................
D35
00
D36
Total: Add lines D31 through D35. Enter here and on the front of this form, line 18................................................................
D36
00
E37
Last name(s) used in prior years if different from name(s) used in current year:
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
FIRM’S NAME (PREPARER’S IF SELF-EMPLOYED)
►
PAID PREPARER’S TIN
DATE
PAID PREPARER’S ADDRESS
If you are sending a payment with this return, mail to Arizona Department of Revenue, PO Box 52016, Phoenix, AZ, 85072-2016.
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.
ADOR 91-0069 (01) slw
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