Form It-150-X - Amended Resident Income Tax Return (Short Form) - New York State Department Of Taxation And Finance - 2009 Page 3

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IT-150-X (2009) Page 3 of 3
 Enter your social security number
Name(s) as shown on page 1
57 Reason(s) for amending your return
( mark an X in all applicable boxes; see instructions )
57a. Federal audit change
57b. Workers’ compensation
57c. Court ruling ................................
( complete lines 58 through 65 below )
57d. Wages ......................................
57e. Military ..........................
57f. Credit claim ................................
57g. Other ........................................
( Explain )
If you marked an X in box 57a above, you must complete lines 58 through 65 below. All others may skip lines 58
through 65 and go directly to the Third-party designee question. You must sign your amended return below.
58 Enter the date
of the
59 Do you concede the federal audit
( mm-dd-yyyy )
final federal determination
changes?
...... Yes
No
( If No, explain below. )
( Explain )
60 List federal changes
Dollars
Cents
60a
60a.
60b
60b.
60c
60c.
60d
60d.
60e
60e.
61 Net federal changes (increase or decrease) ......................................................................................
61.
62 Federal taxable income
..............
62.
( mark an X in one box )
Per return
Previously adjusted
63 Corrected federal taxable income .....................................................................................................
63.
64 Federal credits disallowed .......
Earned income credit
Amount disallowed
Child care credit
Amount disallowed
65 Federal penalties assessed
65a. Fraud .......................................
65b. Negligence ...................
65c. 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 ( see instructions )
 
Date:
 
Taxpayer(s) must sign here
Preparer’s NYTPRIN
Preparer’s signature
Your signature
Preparer’s SSN or PTIN
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.
3623090094
You must file all three pages of this original
scannable amended return with the Tax Department.

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