Arizona Form 140x - Individual Amended Income Tax Return - 2012 Page 2

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Your Name (as shown on page 1)

Your Social Security No.

PART I:

Dependent Exemptions

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 YOUR HOME

FIRST AND LAST NAME:

SOCIAL SECURITY NO.

RELATIONSHIP

DURING 2012

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:

PART II: Qualifying Parents or Grandparents (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 YOUR HOME

FIRST AND LAST NAME:

SOCIAL SECURITY NO.

RELATIONSHIP

DURING 2012

ADD

DELETE

PART III: Income, Deductions, and Credits

On Part III, 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

ITEM

REPORTED

ADD OR SUBTRACT

CORRECTED AMOUNT

.00 $

.00

.00 $

.00

.00 $

.00

.00 $

.00

PART IV: Reason for the Change - give the reason for each changed listed in Part III

PART V: Name and Address on Original Return

If your name and 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 TIN

PAID PREPARER’S ADDRESS

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.

Print Form

ADOR 10573 (12)

Form 140X (2012)

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