Arizona Form 140 - Resident Personal Income Tax Return - 2001 Page 2
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2Form 140 (2001) Page 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 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
PART B: Additions to Income
B6
Non-Arizona municipal interest ..................................................................................................................................................
B6
00
B7
Early withdrawal of Arizona Retirement System contributions not included on your federal return ...........................................
B7
00
B8
Ordinary income portion of lump-sum distributions excluded on your federal return.................................................................
B8
00
B9
Agricultural water conservation expenses .................................................................................................................................
B9
00
B10
Medical savings account (MSA) distributions. See page 6 of the instructions..........................................................................
B10
00
B11
Other additions to income. See instructions and attach your own schedule.............................................................................
B11
00
B12
Total. Add lines B6 through B11. Enter here and on the front of this form, line 13..................................................................
B12
00
PART C: Subtractions from Income
C13
Exemption: Age 65 or over. Multiply the number in box 8, page 1, by $2,100 ...........................
C13
00
C14
Exemption: Blind. Multiply the number in box 9, page 1, by $1,500 ..........................................
C14
00
C15
Exemption: Dependents. Multiply the number in box 10, page 1, by $2,300.............................
C15
00
C16
Exemption: Qualifying parents and ancestors of your parents. Multiply the number in
box 11, page 1, by $10,000..........................................................................................................
C16
00
C17
Total exemptions: Add lines C13 through C16. If you have no other subtractions from
income, skip lines C18 through C27 and enter the amount on line C17 on Form 140, Page 1, line 15. ..........................
C17
00
C18
Interest on U.S. obligations such as U.S. savings bonds and treasury bills ..............................................................................
C18
00
C19
Exclusion for federal, Arizona state or local government pensions (up to $2,500 per taxpayer) ...............................................
C19
00
C20
Arizona state lottery winnings included as income on your federal return (up to $5,000 only) ..................................................
C20
00
C21
U.S. Social Security or Railroad Retirement Act benets included as income on your federal return .......................................
C21
00
C22
Agricultural crops contributed to Arizona charitable organizations ............................................................................................
C22
00
C23
Certain wages of American Indians ...........................................................................................................................................
C23
00
C24
Income tax refund from other states. See instructions..............................................................................................................
C24
00
C25
Deposits and employer contributions into MSAs. See page 9 of the instructions.....................................................................
C25
00
C26
Other subtractions from income. See instructions and attach your own schedule ...................................................................
C26
00
C27
Total: Add lines C17 through C26. Enter here and on the front of this form, line 15................................................................
C27
00
Part D: Last Name(s) Used in Prior Years if different from name(s) used in current year
D28
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 AZ Department of Revenue, PO Box 52016, Phoenix, AZ 85072-2016 (PO Box 29204, Phoenix, AZ 85038-9204 if your return has a bar code).
If you are not sending a payment, mail return to AZ Department of Revenue, PO Box 52138, Phoenix, AZ 85072-2138 (PO Box 29205, Phoenix, AZ 85038-9205 if your return has a bar code).
ADOR 91-5335 (01) slw
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