Arizona Form 140py - Part-Year Resident Personal Income Tax Return

Arizona Form 140PY

For more information, see the department's Medical Savings

You must have made Arizona estimated income tax

Accounts brochure, Pub 542.

payments during 2013 if:

AND

Long-Term

Health

Care

Savings

Account

Your filing status

Your Arizona gross

Your

Arizona

Withdrawal Penalty

is:

income for 2012

gross income for

was greater than:

2013 exceeded:

You must pay a withdrawal penalty if you made a long-term

Married Filing Joint

$150,000

health care savings account withdrawal during 2013 for

Single

$75,000

purposes other than to pay for qualified long-term health

care expenses. Long-term health care expense means any

Head of Household

$75,000

expense you paid for long-term health care costs, including

Married Filing

$75,000

the following:

Separate



expenses for skilled nursing care

If you report as a farmer or fisherman for federal purposes,



you were not required to make estimated payments during

expenses for home health care

2013 if the following apply.



personal care or supportive services due to the loss of

1. You are a calendar year filer. You file your Arizona

some capacity for self-care based on a chronic illness or

return by March 1, 2014. You pay in full the amount

condition

stated on your return as owed.

The penalty is equal to 10% (.10) of the withdrawal. You

2. You are a fiscal year filer. You file your Arizona return

must remit this penalty with your income tax return filed for

the year in which you made the withdrawal.

by the first day of the third month after the end of your

fiscal year. You pay in full the amount stated on your

Multiply the amount of your withdrawal subject to penalty

return as owed.

by 10% (.10). Enter the result on line 52.

If the above applies, check box

2 on line 53 and do not

Line 53 -

complete Form 221.

Box

1 - Check box

1 if any of the following applies to

An individual who fails to make the required estimated

payments is subject to penalty on any estimated tax payment

you.

that is late or underpaid.

1. You checked the box on line 1 of Form 221.

Complete and attach Form 221, Underpayment of Estimated

2. You completed the annualized income worksheet on

Tax by Individuals, to determine if any penalty is due. Enter

Form 221.

the total penalty from Form 221.

You elected to be treated as a nonresident alien on your

MSA Withdrawal Penalty

federal income tax return. You made three estimated

payment installments. Your first installment equaled 50%

You must pay a withdrawal penalty if you made an MSA

of the total of all of your required installments.

withdrawal during 2013 and all of the following apply.

1. You used the amount withdrawn for purposes other than

Box 2 - If you are an individual who for federal purposes reports

to pay for qualified medical expenses.

as a farmer or fisherman, check box

2. You made the withdrawal on a day other than the last

Box 3 - If you completed and attached Form 221, check box

business day of the year.

Box 4 - If you included an MSA penalty on line 52, check box

3. The withdrawal is not subject to the federal withdrawal

Box 5 - If you included an AZLTHSA penalty on line 52, check

penalty.

box

The penalty is equal to 10% of the withdrawal.

The

withdrawal penalty is not subject to abatement. You must

Figuring Your Refund or Tax Due

remit this penalty with your income tax return filed for the

Line 55 - Refund

year in which you made the withdrawal.

Subtract line 54 from line 40. Enter your refund on line 55

Multiply the amount of your withdrawal subject to penalty

and skip line 56.

by 10%. Enter the result. The following withdrawals are not

subject to the penalty.

If you owe money to any Arizona state agency, court,

county, incorporated city or town and certain federal

A withdrawal subject to the federal withdrawal penalty.

agencies, your refund may go to pay some of the debt.

2. Withdrawals made from your MSA on the last business

so, the department will let you know by letter.

day of the tax year.

3. Any withdrawal made by an account holder who is at

Tax Tip: If you change your address before you get your

least age 59 1/2 when he or she makes the withdrawal.

refund, let the department know. Write to: Refund Desk,

NOTE: The following are not withdrawals. Do not enter a

Arizona Department of Revenue, PO Box 29216, Phoenix, AZ

penalty for any of the following.

85038-9216. Include your SSN in your letter.



Amounts from the MSA used to pay qualified medical

Direct Deposit of Refund

expenses



Complete the direct deposit line if you want us to directly

A qualified return of excess contributions



deposit the amount shown on line 55 into your account at a

A qualified rollover



bank or other financial institution (such as a mutual fund,

The fair market value of an MSA received by a surviving

brokerage firm or credit union) instead of sending you a check.

spouse who was the deceased account holder's named

beneficiary

Arizona Form 140py - Part-Year Resident Personal Income Tax Return - 2013 Page 24

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