Form It-201-X - Amended Resident Income Tax Return - 2011 Page 5
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5IT-201-X (2011) Page 5 of 5
Enter your social security number
Name(s) as shown on page 1
83 Reason(s) for amending your return
( mark an X in all applicable boxes; see instructions )
83a. Federal audit change
) ...............................................
83b. Worthless stock/securities ..............
( complete lines 84 through 91 below
83c. Claim of right ..............................
83d. Wages ............................................
83e. Military .............................................
83f. Court ruling ..................................
83g. Workers’ compensation ..................
83h. Treaties/visa ....................................
83i. Tax shelter transaction ................
83j. Credit claim ....................................
83k. Protective claim
......
( see instructions )
83l. Net operating loss
. Mark an X in the box ...
and enter the year of the loss ...
( see instructions )
83m. Other. Mark an X in the box ...
and explain:
83n. To report adjustments to partnership or S corporation income, gain, loss or deduction, provide the following information:
Partnership
S corporation
Name of partnership or S corporation
Identifying number
Principal business activity
Address of partnership or S corporation
If you marked an X in box 83a above, you must complete lines 84 through 91 below. All others may skip lines 84
through 91 and go directly to the Third-party designee question. You must sign your amended return below.
84 Enter the date
of the
85 Do you concede the federal audit
( mm-dd-yyyy )
final federal determination
changes?
...... Yes
No
( If No, explain below. )
( Explain )
86 List federal changes
Dollars
Cents
86a
86a.
86b
86b.
86c
86c.
86d
86d.
86e
86e.
87 Net federal changes (increase or decrease) ............................................................................
87.
88 Federal taxable income
88.
....
( mark an X in one box )
Per return
Previously adjusted
89 Corrected federal taxable income ............................................................................................
89.
90 Federal credits disallowed ........
Earned income credit
Amount disallowed
Child care credit
Amount disallowed
91 Federal penalties assessed
91a. Fraud .............................................
91b. Negligence ........................
91c. Other
..........................
( explain below )
Print designee’s name
Designee’s phone number
Personal identification
Third-party
number (PIN)
(
)
designee ?
( see instr. )
E-mail:
Yes
No
Paid preparer must complete
Taxpayer(s) must sign here
( see instr. )
Date:
Preparer’s NYTPRIN
Preparer’s signature
Your signature
Preparer’s PTIN or SSN
Firm’s name ( or yours, if self-employed )
Your occupation
Address
Employer identification number
Spouse’s signature and occupation (if joint return)
Mark an X if
Daytime phone number
Date
self-employed
E-mail:
E-mail:
See instructions for where to mail your return.
3615110094
You must file all five pages of this original scannable amended return with the Tax Department.
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