Form 740-X - Amended Kentucky Individual Income Tax Return Page 2

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Form 740-X (11-15)

Page 2

*1500030009*

PART I – TAX CREDITS

(This section must be completed for any increase or decrease in the number of personal tax credits claimed

on original return)

1. Number of personal tax credits claimed on original return (Form 740, Section B, lines 3A and 3B) .................................

2. Number of personal tax credits claimed on this return ..........................................................................................................

3. Difference ....................................................................................................................................................................................

Explain any difference in detail below. Include name and Social Security number.

PART II – FAMILY SIZE TAX CREDIT

(This section must be completed for any increase or decrease to Total Family Size claimed on

original return.)

4. Total Family Size claimed on original return

4 or more

5. Total Family Size claimed on this return

4 or more

Explain any difference in detail below. Include name and Social Security number.

PART III – CHANGES

Explain changes to income, deductions and tax from page 1, Column II in detail below. Attach additional or

corrected Kentucky and/or federal forms, schedules or W-2s.

If you do not attach the required information, processing of your Form 740-X may be delayed.

PART IV – INTEREST RATE CHART - Use the following rates when computing interest for amount on Page 1, Line 26.

Jan. 1, 2016–Dec. 31, 2016

–

Jan. 1, 2015–Dec. 31, 2015

–

Jan. 1, 2014–Dec. 31, 2014

–

Jan. 1, 2013–Dec. 31, 2013

–

Jan. 1, 2012–Dec. 31, 2012

–

I, the undersigned, declare under penalties of perjury that I have examined this return, including all accompanying schedules and statements, and, to

the best of my knowledge and belief, it is true, correct and complete. I also understand and agree that our election to file a combined return under the

provisions of appropriate income tax regulations will result in refunds being made payable to us jointly and in each of us being jointly and severally liable

for all taxes accruing under this return.

Your Signature (If a joint or combined return, both must sign.)

Spouse’s Signature

Telephone Number (daytime)

Date Signed

Typed or Printed Name of Preparer Other than Taxpayer

I.D. Number of Preparer

Date

Mail to: Kentucky Department of Revenue, Frankfort, KY 40618-0006.

EFUNDS

Make check payable to:

Kentucky State Treasurer.