Arizona Form 140nr - Nonresident Personal Income Tax Return - 2011 Page 9
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37Form 140NR
Line 9 Box - Blind
Line A2 - Total Dependents
Write "1" in box 9 if you or your spouse are totally or partially
Enter the total number of persons listed on line(s) A1. Enter
blind. Write "2" in box 9 if both you and your spouse are
the same number on the front of the return in box 10.
totally or partially blind.
Lines A3a and A3b - Persons You did Not
If you or your spouse were partially blind as of December
Take as Dependents on Your Federal
31, 2011, you must get a statement certified by your eye
Return
doctor or registered optometrist that:
On line A3a, enter the following.
1. You cannot see better than 20/200 in your better eye with
1. The names of any dependents age 65 or over listed on
glasses or contact lenses or
line(s) A1 that you cannot take as a dependent on your
2. Your field of vision is 20 degrees or less.
federal return.
If your eye condition is not likely to improve beyond the
2. The name of any stillborn child listed on line(s) A1, if
conditions listed above, you can get a statement certified by
the stillborn child was named. If the stillborn child was
your eye doctor or registered optometrist to that effect instead.
not named, enter “stillborn child” on line A3a. Also enter
the date of birth resulting in the stillbirth.
You must keep the statement for your records.
On line A3b, enter the name of any student listed on line(s)
Line 10 Box - Dependents
A1, that you did not claim as an exemption on your federal
You must complete Part A on page 2 of your return before
return in order to allow that student to claim a federal
education credit on the student’s federal return.
you can total your dependent exemptions.
You may claim only the following as a dependent.
Reporting Your Residency Status
x
A person that qualifies as your dependent on your
Check the appropriate box (11 through 13). Check only one box.
federal return.
Line 11 Box - Nonresident
NOTE: If you do not claim a dependent exemption for a
Check box 11 if you were not an Arizona resident during
student on your federal return in order to allow the student
2011, and were not on active military duty in Arizona.
to claim a federal education credit on the student’s federal
return, you may still claim the exemption on your Arizona
Line 12 Box - Nonresident Active Military
return.
For more information, see Arizona Individual
Check box 12 if you were a nonresident on active duty
Income Tax Ruling ITR 05-02.
military assignment in Arizona during 2011.
x
A person who is age 65 or over (related to you or not)
Line 13 Box - Composite Return
that does not qualify as your dependent on your federal
return, but one of the following applies.
Check box 13 if this is a composite return being filed by one
1.
In 2011, you paid more than one-fourth of the cost of
of the following.
keeping this person in an Arizona nursing care institution,
1. A partnership filing on behalf of its nonresident
an Arizona residential care institution, or an Arizona
partners.
assisted living facility. Your cost must be more than $800.
2. An S corporation filing on behalf of its nonresident
2. In 2011, you paid more than $800 for either Arizona
shareholders.
home health care or other medical costs for the person.
For information on filing an Arizona nonresident composite
x
A stillborn child if the following apply:
income tax return, see Arizona Department of Revenue
1. The stillbirth occurred in Arizona during 2011.
Income Tax Ruling ITR 97-1.
2. You received a certificate of birth resulting in stillbirth
Determining Arizona Income
from the Arizona Department of Health Services.
Now complete Parts B, C, and D on page 2 of the return.
3. The child would have otherwise been a member of your
household.
Use Part B to determine what portion of your total income is
taxable by Arizona.
Completing Line(s) A1
Enter the following on line(s) A1.
NOTE: If you are unable to determine the proper line to
1. The dependent's name.
If you are claiming an
use, please call one of the numbers listed on the back cover.
exemption for a stillborn child and the child was not
named, enter “stillborn child” in place of a name.
FEDERAL Column
2. The dependent's SSN. If you are claiming an exemption
Enter the actual amounts shown on your 2011 federal
for a stillborn child enter the certificate number from
income tax return in the FEDERAL column. Complete lines
the certificate of birth resulting in stillbirth.
B5 through B15. Line B15 should equal the federal adjusted
3. The dependent's relationship to you.
gross income shown on your 2011 federal return Form 1040,
Form 1040A, or Form 1040EZ.
4.
The number of months the dependent lived in your home
during 2011. If you are claiming an exemption for a
ARIZONA Column
stillborn child, enter the date of birth resulting in the
stillbirth.
Enter that portion of your federal income received from
Arizona sources in the ARIZONA column. Such income
You may lose the exemption if you do not furnish this
includes wages earned in Arizona, Arizona rental and
information.
business income, and gains on the sale of Arizona property.
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