Form Ia 1040x - Amended Iowa Individual Income Tax Return
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4IA 1040X
For fiscal year beginning ___/___/_____ and ending ___/___/_____
STEP 1
Amended Iowa Individual Income Tax Return
A.
Your first name/middle initial
Last name
Social Security Number
B.
Spouse’s first name/middle initial
Last name
Social Security Number
Current Mailing address (number and street or PO Box):
Residence on 12/31 of
For Calendar Year
Check this box if you or your
year being amended
spouse were 65 or older at the end
__ __ __ __
County No: _____________
City, town or post office, state, ZIP code
of the tax year.
Sch. Dist. No: ___________
Reason for
STEP 2 Filing Status: Mark correct status.
Amendment:
1
Single: Were you claimed as a dependent on another person’s Iowa return for the year being amended?
YES
NO
NONNO
Net Operating Loss
2
Married filing a joint return.
Federal Audit
3
Married filing separately on this combined return. Spouse use column B.
Protective Claim
4
Married filing separate returns. Spouse’s name:
SSN:
Income: $
Other
5
Head of household with qualifying person.
If qualifying person is not claimed as a dependent on this return, enter the person’s name and Social Security Number here.
Provide detailed
explanation on back.
6
Qualifying widow(er) with dependent child.
Name:
SSN:
STEP 3
Personal Credit: Enter 1 or Enter 2 if filing joint or head of household ...................... _______
X $ _________ = $ __________
YOU
20
Corrected
Enter 1 for each person who is 65 or older and/or 1 for each person who is blind ........ _______
X $ _________ = $ __________
(and spouse IF
Exemptions
filing jointly)
40
Dependents: Enter 1 for each dependent ......................................................................... _______
X $ _________ = $ __________
Enter first names of dependents here: _______________________________________
TOTAL $ ______________
Personal Credit: Enter 1 ..................................................................................................... _______
X $ _________ = $ __________
SPOUSE
20
Enter 1 if 65 or older and/or 1 if blind ................................................................................. _______
X $ _________ = $ __________
(IF filing
40
status 3)
Dependents: Enter 1 for each dependent ......................................................................... _______
X $ _________ = $ __________
Enter first names of dependents here: _______________________________________
TOTAL $ ______________
B. Spouse/Status 3
A. You or Joint
STEP 4
1. Gross Income ....................................................................................................................................................................... 1. ______________ .00 ________________ .00
Corrected
Taxable
2. Adjustments to Income ........................................................................................................................................................ 2. ______________ .00 ________________ .00
Income
3. Net Income. Subtract line 2 from line 1. ............................................................................................................................ 3. ______________ .00 ________________ .00
4. Addition for Federal Taxes ................................................................................................................................................ 4. ______________ .00 ________________ .00
5. Total. Add lines 3 and 4. .................................................................................................................................................... 5. ______________ .00 ________________ .00
6. Deduction for Federal Taxes ............................................................................................................................................. 6. ______________ .00 ________________ .00
7. Balance. Subtract line 6 from line 5. ................................................................................................................................. 7. ______________ .00 ________________ .00
8. Deduction: Itemized / Standard ......................................................................................................................................... 8. ______________ .00 ________________ .00
9. Taxable Income. Subtract line 8 from line 7. ..................................................................................................................... 9. ______________ .00 ________________ .00
STEP 5
10. Tax or Alternative Tax ....................................................................................................................................................... 10. ______________ .00 ________________ .00
Figure
11. Iowa Lump Sum/Minimum Tax .......................................................................................................................................... 11. ______________ .00 ________________ .00
Your Tax
and
12. Total Tax. Add lines 10 and 11. ........................................................................................................................................ 12. ______________ .00 ________________ .00
Credits
13. Total of Exemption Credits, Earned Income Credit (ONLY for years 2006 and prior), and Tuition and Textbook Credit 13. ______________ .00 ________________ .00
14. Balance. Subtract line 13 from line 12. If less than zero, enter zero. ............................................................................... 14. ______________ .00 ________________ .00
15. Credit for Nonresident or Part-Year Resident. Attach IA 126. .......................................................................................... 15. ______________ .00 ________________ .00
16. Balance. Subtract line 15 from line 14. If less than zero, enter zero. ............................................................................... 16. ______________ .00 ________________ .00
17. Other Iowa Credits. Attach IA 148 Tax Credits Schedule. ................................................................................................ 17. ______________ .00 ________________ .00
18. Balance. Subtract line 17 from line 16. If less than zero, enter zero. ............................................................................... 18. ______________ .00 ________________ .00
19. School District Surtax/Emergency Medical Services Surtax ............................................................................................ 19. ______________ .00 ________________ .00
20. Contributions from Original Return .................................................................................................................................... 20. ______________ .00 ________________ .00
21. Total Tax. Add lines 18, 19, and 20. ................................................................................................................................. 21. ______________ .00 ________________ .00
STEP 6
22. Total. Add columns A & B, line 21, and enter here. .............................................................................................................................................. 22. ________________ .00
Refund
23. Total Credits B & A from Step 9 of the IA 1040. See instructions. ....................................................................................................................... 23. ________________ .00
or
Amount
24. Tax amount previously paid .................................................................................................................................................................................. 24. ________________ .00
You Owe
25. Total credits and payments. Add lines 23 and 24. ................................................................................................................................................. 25. ________________ .00
26. Overpayment shown on previous filing .................................................................................................................................................................. 26. ________________ .00
27. Subtract line 26 from line 25. Enter here. .............................................................................................................................................................. 27. ________________ .00
28. If line 27 is more than line 22, subtract line 22 from line 27. This is the REFUND amount. ............................................................. REFUND
28. ________________ .00
29. If line 27 is less than line 22, subtract line 27 from line 22. This is the AMOUNT OF TAX YOU OWE. .............................................................. 29. ________________ .00
30. Penalty and Interest. See instructions.
30a. Penalty__________
+30 b. Interest__________ ................ 30. ________________ .00
31. TOTAL AMOUNT NOW DUE. Add lines 29 and 30 and enter here. Make check payable to Treasurer, State of Iowa ........................ PAY
31. ________________ .00
I (We), the undersigned, declare under penalty of perjury that I (we) have examined this return and attachments, and, to the best of my (our) knowledge and belief, it is a true, correct,
and complete return. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Preparer’s Signature: ___________________________ Date: ____________________
Your Signature: ____________________________________________ Date: __________
Firm: ________________________________________ Phone: __________________
Address: _____________________________________
Spouse’s Signature: ________________________________________ Date: __________
____________________________________________ ID#: _____________________
X
Daytime Telephone Number: ______________________________________
41-122a (06/08/09)
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