Arizona Form 140nr - Nonresident Personal Income Tax Return

FOR

ARIZONA FORM

Application for Filing Extension

CALENDAR YEAR

204

2011

For Individual Returns Only

M M D D Y Y Y Y

OR FISCAL YEAR BEGINNING

AND ENDING

Your First Name and Initial

Last Name

Your Social Security No.

You must

enter your

If a joint return, Spouse’s First Name and Initial

Last Name

Spouse’s Social Security No.

SSN(s).

Present Home Address - number and street, rural route

Apt. No.

Daytime Phone (with area code) Home Phone (with area code)

City, Town or Post Office

State

Zip Code

REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

†

Check box 1

Check box 1 if you are a first time Arizona income tax return filer

if you are a first time Arizona income tax return filer.............

............. 1

Resident Personal Income Tax Forms – Check only one box:

†

140

140A

140EZ

140PTC

140ET

†

Part-Year Resident Personal Income Tax, Form 140PY

†

Nonresident Personal Income Tax, Form 140NR

All extension requests must be postmarked on or before

An Arizona extension cannot be granted for more than

the original due date of the return, unless the original due

six months beyond the original due date of the return.

date falls on a Saturday, Sunday, or legal holiday. In that

Arizona will grant an automatic six-month extension to

case, your request must be postmarked on or before the

individuals filing Forms 140, 140A, 140EZ, 140NR, 140PY,

business day following that Saturday, Sunday, or legal

140PTC or 140ET.

Arizona will accept a valid federal

holiday. If you are a calendar year filer, your request for

extension for the period covered by the federal extension.

a 2011 filing extension must be postmarked on or before

This includes the automatic six-month individual federal

April 17, 2012.

filing extension.

Fiscal Tax Year Ending

Return Due Date

CHECK ONE BOX:

† †

Individual Calendar Year Filers:

(filing Forms 140, 140A, 140EZ, 140NR, 140PY, 140PTC or 140ET)

October 15, 2012

This is a request for an automatic 6-month filing extension ..................................

†

Individual Fiscal Year Filers:

(automatic 6-month extension period)

Enter taxable year-end date and 6-month extended due date ..............................

M M D D Y Y Y Y M M D D Y Y Y Y

†

A federal extension will be used to file this tax return. This form is being used to transmit the Arizona extension payment.

1 Tax liability for 2011. You may estimate this amount ...................................................................................

2 Arizona income tax withheld during 2011 ....................................................................

3 Arizona estimated tax payments for 2011 ....................................................................

4 Credits you will claim on your 2011 return. See Form 301 for a list of credits ............

5 Add lines 2 through 4 ....................................................................................................................................

6 Balance of Tax: Subtract line 5 from line 1 .................................................................................................

7 Enter the amount of payment. Round your payment to the nearest dollar ..................................................

• Make check payable to Arizona Department of Revenue and write your SSN on your payment.

• Attach your payment to the upper left corner of this page.

• IMPORTANT: If you are filing under a federal extension but are making an Arizona extension payment by credit card or

electronic payment, do not mail Form 204 to us. We will apply your estimated tax payment to your account.

• If you are sending a payment with this request, mail to Arizona Department of Revenue,

PO Box 29085, Phoenix, AZ 85038-9085.

• If you are not sending a payment with this request, mail to Arizona Department of Revenue,

PO Box 52138, Phoenix, AZ 85072-2138.

ADOR 10576 (11)

Arizona Form 140nr - Nonresident Personal Income Tax Return - 2011 Page 24

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