Form Ri-1040x-R - Amended Rhode Island Resident Individual Income Tax Return - 2012 Page 2
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5Amended Rhode Island Resident Individual Income Tax Return
RI-1040X-R
2012
(To be used by resident taxpayers only)
Name(s) shown on Form RI-1040X-R
Your social security number
PART 2 EXPLANATION OF CHANGES TO INCOME, DEDUCTIONS AND CREDITS
Enter the line number from the form for each item you are changing and give the reason for each change. Attach only the supporting forms
and schedules for the items changed. If you do not attach the required information, your Form RI-1040X-R may be returned.
Under penalties of perjury, I declare that I have examined this return, and to the best of my knowledge and belief, it is true, correct and complete.
Your
Spouse’s
Signature
Signature
Date
Date
May the division contact your preparer about this return? Yes
Paid preparer’s signature and address
SSN, PTIN or EIN
Date
Paid preparer’s address
Paid preparer’s telephone number
page 2
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