Form 200-01-X - Resident Amended Personal Income Tax Return - 2013 Page 2

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FORM 200-01-X

2013

Page 2

RESIDENT AMENDED PERSONAL INCOME TAX RETURN

*DF21113029999*

NOTE: IF YOUR ORIGINAL RETURN WAS FILED USING TWO SEPARATE FORMS, YOU MUST FILE TWO SEPARATE AMENDED FORMS

IS AN AMENDED FEDERAL RETURN BEING FILED?.........................................................................................................

YES

IF NO, PLEASE EXPLAIN. IF THE CHANGES PERTAIN TO THE DE RETURN ONLY, LIST THE LINE NUMBERS BEING AMENDED.

YES

HAS THE DELAWARE DIVISION OF REVENUE ADVISED YOU YOUR ORIGINAL RETURN IS BEING AUDITED?.........

IS THIS AMENDED RETURN BEING FILED AS A PROTECTIVE CLAIM?........................................................................

YES

A DETAILED EXPLANATION OF ALL CHANGES MUST BE PROVIDED IN THIS SPACE. ALL SUPPORTING SCHEDULES AND/OR DOCUMENTATION MUST BE ATTACHED

(Reconcile your Federal totals to the

Filing Status 4 ONLY

Spouse Information

You or You plus Spouse

MODIFICATIONS TO FEDERAL ADJUSTED GROSS INCOME

COLUMN A

COLUMN B

SECTION A - ADDITIONS (+)

32.

Enter Federal AGI amount. See Instructions.......................................................................................................

33. Interest on State & Local obligations other than Delaware...................................................................

34. Fiduciary adjustment, oil depletion..........................................................................................................

35. TOTAL - Add Lines 33 and 34.....................................................................................................................

36. Subtotal. Add Lines 32 and 35...........................

SECTION B - SUBTRACTIONS (-)

37. Interest received on U.S. Obligations......................................................................................................

38. Pension/Retirement Exclusions

(See Instructions.)...............................................................................

39. Delaware State t ax refund,

duciary adjustment, work opportunity tax credit,

Delaware NOL Carry forward.....................................................................................................................

40.

41. SUBTOTAL. Add Lines 37, 38, 39 and 40 and enter here.........................................................................................

42. Subtotal. Subtract Line 41 from Line 36...............

43. Exclusion for certain persons 60 and over or disabled ................................................................................................

44. TOTAL - Add Lines 41 and 43..........................................................................................................................................

45.

DELAWARE ADJUSTED GROSS INCOME. Subtract line 44 from Line 36. Enter here and on Front, Line 1....

SECTION C - ITEMIZED DEDUCTIONS (MUST ATTACH FEDERAL SCHEDULE A) If

allocate deductions between spouses, you must prorate in accordance with income.

46. Enter total Itemized Deductions. (See Ins tructions)...................................................................................................

47. Enter Foreign Taxes Paid (See I nstructions) .............................................................................................................

48. Enter Charitable Mileage Deduction (See Instructions)..........................................................................

49. SUBTOTAL. - Add Lines 46, 47 , and 48 and enter here.............................................................................................

50a. Enter State Income Tax included in Line 46 above (See Instructions)..................................................

50a

50b. Enter Form 700 Tax Credit Adjustment (See Instructions).....................................................................

50b

51.

TOTAL - Subtract Line 50a and 50b from Line 49. Enter here and on Front, Line 2 (See Instructions).......

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and believe it is true, correct and complete.

YOUR SIGNATURE

TELEPHONE NUMBER

SPOUSE SIGNATURE (If Filing Joint)

DATE

SIGNATURE OF PREPARER

PREPARER’S EIN OR SSN

PREPARER’S PHONE

DATE

STREET ADDRESS OF PREPARER

CITY

STATE

ZIP