Form 140x - Individual Amended Income Tax Return

Form 140X (2001) Page 2

ADOR 91-0018 (01) slw

PART I: Dependent Exemptions - do not list yourself or spouse as dependents

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 2001

For 1997, enter the names of the dependents listed above who do not qualify as your dependent on your federal return because:

(1) The dependent’s income was equal to or more than the federal exemption amount for the year ....

(2) The dependent ﬁ led a joint federal return with his/her spouse .........................................................

(3) You claimed the dependent under the Arizona “age 65 or over” rules..............................................

For 1998, 1999, 2000 and 2001, enter the names of any dependents age 65 or over listed above that you cannot claim as a dependent on your

1998, 1999, 2000 or 2001 federal return:

PART II: Qualifying Parents and Ancestors of Your Parents Exemptions 1999, 2000 or 2001 (Arizona residents only)

List below qualifying parents and ancestors of your parents for which you are claiming an exemption. If more space is needed, attach a separate sheet.

Do not list the same person here that you listed in Part I, above, as a dependent. For information on who is a qualifying parent or ancestor of your

parents, see the instructions for the original return that you ﬁ led.

NO. OF MONTHS LIVED

FIRST AND LAST NAME

SOCIAL SECURITY NO.

RELATIONSHIP

IN YOUR HOME IN 2001

PART III: Income, Deductions, and Credits

List the line reference from page 1 for which you are reporting a change then give the reason for each change. Attach any supporting documents

required. If the change(s) pertain(s) to an IRS audit, please attach a copy of the agent’s report. If you ﬁ led an amended federal return with the IRS

(Form 1040X), please attach a copy and all supporting schedules.

Part IV: Name and Address on Original Return

If your name and address is the same on this amended return as it was on your original return, write “same” on the line below.

Name

Number and Street, etc.

City, State Zip

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 91-0018 (01) slw

Form 140x - Individual Amended Income Tax Return - 2001 Page 2

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