IT-201-X
New York State Department of Taxation and Finance
Amended Resident Income Tax Return
•
•
New York State
New York City
Yonkers
1 1
For the full year January 1, 2011, through December 31, 2011, or fiscal year beginning ....
and ending ....
See the instructions, Form IT-201-X-I, for help completing your amended return.
You must enter your date(s) of birth and social security number(s) below.
Your social security number
Your first name and middle initial Your last name
( for a joint return, enter spouse’s name on line below )
Your date of birth (MMDDYYYY)
Spouse’s first name and middle initial Spouse’s last name
Spouse’s social security number
Spouse’s date of birth (MMDDYYYY)
Mailing address
Apartment number
New York State county of residence
( number and street or rural route )
City, village, or post office
State
ZIP code
Country
School district name
( if not United States )
Permanent home address
Apartment number
( number and street or rural route )
School district
code number ....................
City, village, or post office
State
ZIP code
Taxpayer’s date of death Spouse’s date of death
Decedent
NY
information
(D)
Did you file an amended federal
(A) Filing
Single
return?
.....................................
Yes
No
( see instructions )
status —
(E)
(1) Did you or your spouse maintain living
Married filing joint return
mark an
quarters in NYC during 2011?......................
Yes
No
( enter spouse’s social security number above )
X in
(2) Enter the number of days spent in NYC in 2011
one box:
Married filing separate return
......
( any part of a day spent in NYC is considered a day )
( enter spouse’s social security number above )
(F)
NYC residents and NYC part-year
residents only:
Head of household
( with qualifying person )
(1) Number of months you lived in NY City in 2011
............
Qualifying widow(er) with dependent child
(2) Number of months your spouse
(B)
Did you itemize your deductions on
..................................................
lived in NY City in 2011
your 2011 federal income tax return? .......
Yes
No
(G)
Enter your 2-character special condition code
(C)
Can you be claimed as a dependent
if applicable
..........................................
( see instructions )
Yes
No
on another taxpayer’s federal return? .......
If applicable, also enter your second 2-character
special condition code ....................................................
Federal income and adjustments
Dollars
Cents
1 Wages, salaries, tips, etc. ...........................................................................................................
1.
2 Taxable interest income ..............................................................................................................
2.
3 Ordinary dividends ......................................................................................................................
3.
4 Taxable refunds, credits, or offsets of state and local income taxes
.........
4.
( also enter on line 25 )
5 Alimony received .........................................................................................................................
5.
6 Business income or loss
6.
.........................
( attach a copy of federal Schedule C or C-EZ, Form 1040 )
7 Capital gain or loss
..............................
7.
( if required, attach a copy of federal Schedule D, Form 1040 )
8 Other gains or losses
.............................................................
8.
( attach a copy of federal Form 4797 )
9 Taxable amount of IRA distributions. If received as a beneficiary, mark an X in the box ....
9.
10 Taxable amount of pensions and annuities. If received as a beneficiary, mark an X in the box
10.
11 Rental real estate, royalties, partnerships, S corporations, trusts, etc.
11.
( attach copy of federal Schedule E, Form 1040 )
12 Farm income or loss
............................................. 12.
( attach a copy of federal Schedule F, Form 1040 )
13 Unemployment compensation .................................................................................................... 13.
14 Taxable amount of social security benefits
................................................. 14.
( also enter on line 27 )
15 Other income ............
Identify:
15.
16 Add lines 1 through 15 ................................................................................................................ 16.
17 Total federal adjustments to income .......
Identify:
17.
18 Federal adjusted gross income
.................................................... 18.
( subtract line 17 from line 16 )
3611110094
You must file all five pages of this original scannable amended return with the Tax Department.