IT-203-X (2010) Page 5 of 5
Enter your social security number
Name(s) as shown on page 1
77 Reason(s) for amending your return
( mark an X in all applicable boxes; see instructions )
77a. Federal audit change
) .................................................
77b. Military ...........................................
( complete lines 78 through 85 below
77c. Court ruling ....................................
77d. Treaties / visa ..................................
77e. Tax shelter transaction ....................
77f. Wages allocation ...........................
77g. Worthless stock / securities ............
77h. Workers’ compensation .................
77i. Claim of right .................................
77j. Credit claim ....................................
77k. Protective claim
....
( see instructions )
77l. Net operating loss
. Mark an X in the box ...
and enter the year of the loss ....
( see instructions )
77m. Other. Mark an X in the box ...
and explain:
77n. 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 77a above, you must complete lines 78 through 85 below. All others may skip lines 78
through 85 and go directly to the Third-party designee question. You must sign your amended return below.
78 Enter the date
of the
79 Do you concede the federal audit
( mm-dd-yyyy )
–
–
final federal determination
changes?
...... Yes
No
( If No, explain below. )
( Explain )
Dollars
Cents
80 List federal changes
80a
80a.
80b
80b.
80c
80c.
80d
80d.
80e
80e.
81 Net federal changes (increase or decrease) .............................................................................
81.
82 Federal taxable income
82.
.......
( mark an X in one box )
Per return
Previously adjusted
83 Corrected federal taxable income ............................................................................................
83.
84 Federal credits disallowed ........
Earned income credit
Amount disallowed
Child care credit
Amount disallowed
85 Federal penalties assessed
85a. Fraud .............................................
85b. Negligence ........................
85c. 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 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)
Daytime phone number
Mark an X if
Date
self-employed
E-mail:
E-mail:
See instructions for where to mail your return.
3635100094
You must file all five pages of this original scannable amended return with the Tax Department.