Arizona Form 140x - Individual Amended Income Tax Return - 2013 Page 2
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1
2Your Name (as shown on page 1)
Your Social Security No.
Complete Part I only if you are making a change to the number of dependents you are claiming on line 15. Even if not making a change, enter the
total number you are claiming on page 1, line 15. Do not list yourself or your spouse as dependents on line 15.
NO. OF MONTHS LIVED IN
a1
FIRST AND LAST NAME:
SOCIAL SECURITY NO.
RELATIONSHIP
YOUR HOME IN 2013
ADD
DELETE
a2 If adding dependents, enter the name of any dependent added above who does not qualify as a dependent on your federal return:
a3 If adding dependents, enter the name of any dependent added above not claimed as a dependent on your federal return due to education credits:
QualiFying DepenDents (arizona resiDents only): Complete Part II only if you are making a change to the number of qualifying parents
or grandparents you are claiming on page 1, line 16. Even if not making a change, enter the total number you are claiming on page 1, line 16.
NO. OF MONTHS LIVED IN
FIRST AND LAST NAME:
SOCIAL SECURITY NO.
RELATIONSHIP
YOUR HOME IN 2013
ADD
DELETE
income, DeDuctions, creDits: In column (a), list the items you are changing. In column (b), enter the amount claimed on your original return or
most recent amended return. In column (c), enter the amount of the change. In column (d), enter the corrected amount for the item you are changing.
(a)
(b)
(c)
(d)
ORIgINAL AMOUNT
AMOUNT TO
ITEMS YOU ARE CHANgINg
REPORTED
ADD OR SUBTRACT
CORRECTED AMOUNT
$
$
$
$
$
$
$
$
$
long-term capital gain: If you are changing the amount of the allowable subtraction from income for any net long-term capital gains
included in your federal adjusted gross income from assets acquired after December 31, 2011, complete columns b, c, and d.
(a)
(b)
(c)
(d)
ORIgINAL AMOUNT
AMOUNT TO
ITEM
REPORTED
ADD OR SUBTRACT
CORRECTED AMOUNT
total net short-term capital gain or (loss) reported on
$
$
$
Form 140, line D31; Form 140NR, line E33; Form 140PY, line E37 .............
total net long-term capital gain or (loss) reported on
$
$
$
Form 140, line D32; Form 140NR, line E34; Form 140PY, line E38 .............
net long-term capital gains from assets acquired after
December 31, 2011 reported on Form 140, line D33;
$
$
$
Form 140NR, line E35; Form 140PY, line E39 .............................................
amount of allowable subtraction reported on Form 140, line 16;
$
$
$
Form 140NR, line 19; Form 140PY, line 19 ..................................................
reason For tHe cHange: give the reason for each changed listed in Part III:
If your address is the same on this amended return as it was on your original return, write “same” on the line below.
Name
Number and Street, R.R.
Apt. No. City, Town or Post Office
State
ZIP Code
I have read this return and any attachments with it. Under penalties of perjury, I declare that to the best of my knowledge and belief, they are
true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
YOUR SIgNATURE
DATE
OCCUPATION
SPOUSE’S SIgNATURE
DATE
SPOUSE’S OCCUPATION
PAID PREPARER’S SIgNATURE
DATE
FIRM’S NAME (PREPARER’S IF SELF-EMPLOYED)
PAID PREPARER’S STREET ADDRESS
PAID PREPARER’S TIN
PAID PREPARER’S CITY
STATE
ZIP CODE
PAID PREPARER’S PHONE NO.
If you are sending a payment with this return, mail to Arizona Department of Revenue, PO Box 52016, Phoenix, AZ, 85072-2016.
If you are expecting a refund or owe no tax, or owe tax but are not sending a payment, mail to Arizona Department of Revenue, PO Box 52138, Phoenix, AZ, 85072-2138.
ADOR 10573 (13)
Form 140X (2013)
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