Arizona Form 140a - Resident Personal Income Tax Return (Short Form) - 2011 Page 15
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33Your Name (as shown on page 1)
Your Social Security No.
PART A: Dependents, Qualifying Parents and Grandparents -
do not list yourself or spouse
List children and other dependents. If more space is needed, attach a separate sheet.
A1
NO. OF MONTHS LIVED
FIRST AND LAST NAME
SOCIAL SECURITY NO.
RELATIONSHIP
IN YOUR HOME IN 2011
Enter total number of persons listed in A1 here and on the front of this form, box 10 .......................................... TOTAL
A2
A2
a Enter the names of the dependents listed above who do not qualify as your dependent on your federal return. See
A3
page 6 of the instructions.
b Enter dependents listed above who were not claimed on your federal return due to education credits:
List qualifying parents and grandparents. If more space is needed, attach a separate sheet.
A4
You cannot list the same person here and also on line A1. For information on who is a
qualifying parent or grandparent, see page 6 of the instructions.
NO. OF MONTHS LIVED
FIRST AND LAST NAME
SOCIAL SECURITY NO.
RELATIONSHIP
IN YOUR HOME IN 2011
Enter total number of persons listed in A4 here and on the front of this form, box 11 .......................................... TOTAL
A5
A5
PART B: Last Name(s) Used in Prior Years
– if different from name(s) used in current year
B6
I have read this return and any attachments with it. Under penalties of perjury, I declare that to the best of my knowledge and belief, they are true,
correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
YOUR SIGNATURE
DATE
OCCUPATION
SPOUSE’S SIGNATURE
DATE
SPOUSE’S OCCUPATION
PAID PREPARER’S SIGNATURE
DATE
FIRM’S NAME (PREPARER’S IF SELF-EMPLOYED)
(
)
PAID PREPARER’S TIN
PAID PREPARER’S ADDRESS
PAID PREPARER’S PHONE NO.
If you are sending a payment with this return, mail to Arizona Department of Revenue, PO Box 52016, Phoenix, AZ, 85072-2016.
If you are expecting a refund or owe no tax, or owe tax but are not sending a payment, mail to Arizona Department of Revenue, PO Box 52138, Phoenix, AZ, 85072-2138.
ADOR 10414 (11) Eff. 8/2/2012
AZ Form 140A (2011)
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