Form D-40x - Amended Individual Income Tax Return

Form D-40x - Amended Individual Income Tax Return - 2009 Page 2

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Page 2

PART I - Exemptions

If exemptions are unchanged or are decreased, do not complete lines 6 and 7.

COLUMN 1

COLUMN 2

As Previously Reported

Corrected Amount

1 Exemptions—yourself and spouse, 65 or over, blind . . . . . . . . . . . . . . . . . . . . . . . . . .

2 Your dependent children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3 Other dependents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4 Total exemptions (add lines 1, 2, and 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5 Multiply the exemption amount by the total number of exemptions claimed on line 4

for each applicable tax year. For the proper amount see the tax booklet for the tax year

being amended. Enter here and on page 1, line 6 . . . . . . . . . . . . . . . . . . . . . . . . . . .

6 Enter first names of your dependent children who were not claimed on the original return and their social security numbers:

Corrected Number

Enter number

7 List other dependents not claimed on original

(d) Did dependent have

(e) Did you provide more

Corrected Number

of Months

income equal to or more

than one half of

return (and their SSNs):

(b) Relationship

lived in

than the applicable tax

dependent’s support?

your home

year exemption amount

(enter Yes or No)

Enter number

(enter Yes or No)

PART II - Explanation of Changes to Income, Deductions, and Credits

Enter the line number from page 1 for which you are reporting a change and give the reason for each change made.

Attach applicable federal tax schedules and statements.

Form D-40x - Amended Individual Income Tax Return - 2009 Page 2