New York State Department of Taxation and Finance
IT-201-X
Amended Resident Income Tax Return
•
•
New York State
New York City
Yonkers
For the full year January 1, 2012, through December 31, 2012, or fiscal year beginning ....
1 2
and ending ....
See the instructions, Form IT-201-X-I, for help completing your amended return.
Your first name and middle initial
Your last name
Your social security number
Your date of birth (mm-dd-yyyy)
(for a joint return, enter spouse’s name on line below)
Spouse’s first name and middle initial Spouse’s last name
Spouse’s social security number
Spouse’s date of birth (mm-dd-yyyy)
New York State county of residence
Mailing address
Apartment number
(number and street or rural route)
City, village, or post office
State
ZIP code
Country
School district name
(if not United States)
Apartment number
Permanent home address
(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
Did you file an amended federal
D
A Filing
Single
return?
......................................... Yes
No
(see instructions)
status
(1) Did you or your spouse maintain living
Married filing joint return
E
(mark an
quarters in NYC during 2012? ........................ Yes
No
(enter spouse’s social security number above)
X in one
(2) Enter the number of days spent in NYC in 2012
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
Head of household
(with qualifying person)
residents only:
(1) Number of months you lived in NYC in 2012 ...................
Qualifying widow(er) with dependent child
(2) Number of months your spouse
lived in NYC in 2012 ..........................................................
Did you itemize your deductions on
B
your 2012 federal income tax return? ............. Yes
No
Enter your 2-character special condition code
G
if applicable
.................................................
(see instructions)
Can you be claimed as a dependent
C
on another taxpayer’s federal return? ............. Yes
No
If applicable, also enter your second 2-character
special condition code ...........................................................
H Dependent exemption information
First name and middle initial
Last name
Relationship
Social security number
Date of birth
(mm-dd-yyyy)
If more than 9 dependents, mark an X in the box.
361001120094