Arizona Form 140a - Resident Personal Income Tax Return (Short Form) - 2002 Page 2
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2Form 140A (2002) Page 2 of 2
PART A: Dependents - do not list yourself or spouse
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 2002
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 pages 4 and 5 of the instructions.
NO. OF MONTHS LIVED
FIRST AND LAST NAME
SOCIAL SECURITY NO.
RELATIONSHIP
IN YOUR HOME IN 2002
A5 Enter total number of persons listed in A4 here and on the front of this form, box 11. .......................................................TOTAL
A5
PART B: Last Name(s) Used in Prior Years if different from name(s) used in current year
B6
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.
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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 91-0012 (02)
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