Arizona Form 140py - Part-Year Resident Personal Income Tax Return - 2012 Page 2

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Your Name (as shown on page 1)

Your Social Security No.

A1 List children and other dependents. Do not list yourself or spouse. If more space is needed,

attach a separate sheet.

NO. OF MONTHS LIVED

FIRST AND LAST NAME

SOCIAL SECURITY NO.

RELATIONSHIP

IN YOUR HOME IN 2012

A2 Enter total number of persons listed in A1 here and on the front of this form, box 10 ............................................ TOTAL

A3 a Enter the names of the dependents listed above who do not qualify as your dependent on your federal return:

b Enter dependents listed above who were not claimed on your federal return due to education credits:

A4 List qualifying parents and grandparents. If more space is needed, attach a separate sheet.

You cannot list the same person here and also on line A1. For information on who is a

qualifying parent or grandparent, see page 5 of the instructions.

NO. OF MONTHS LIVED

FIRST AND LAST NAME

SOCIAL SECURITY NO.

RELATIONSHIP

IN YOUR HOME IN 2012

A5 Enter total number of persons listed in A4 here and on the front of this form, box 11 ............................................ TOTAL

M M D D Y Y Y Y

B6 Dates of Arizona residency:

From

2012 FEDERAL

2012 ARIZONA

Amount from Federal Return

Amount Only

List other state(s) of residency:

B7 Wages, salaries, tips, etc. ..............................................................................................................

B8 Interest ............................................................................................................................................

B9 Dividends ........................................................................................................................................

B10 Arizona income tax refunds ............................................................................................................ B10

B11 Alimony received ............................................................................................................................ B11

B12 Business income (or loss) from federal Schedule C ....................................................................... B12

B13 Gains (or losses) from federal Schedule D ..................................................................................... B13

B14 Rents, royalties, partnerships, estates, trusts, small business corporations

. B14

from federal Schedule E

B15 Other income reported on your federal return ................................................................................ B15

B16 Total income:

............................................................................................. B16

Add lines B7 through B15

B17 Federal adjustments.

................................................................................ B17

Attach your own schedule

B18 Federal adjusted gross income:

..................... B18

Subtract line B17 from line B16 in the FEDERAL column

B19 Arizona income:

..............

B19

Subtract line B17 from line B16 in the ARIZONA column. Enter here and on the front of this form, line 15

B20 Arizona percentage:

.............................................................

B20

Divide line B19 by line B18, and enter the result (not over 100%)

C21 I.R.C. §179 expense in excess of allowable amount.

...................................................

C21

Also see the instructions for line D34

C22 Total depreciation included in Arizona gross income .........................................................................................................

C22

C23 Other additions to income:

..............................................................................

C23

See instructions and attach your own schedule

C24 Total:

..................................................................

C24

Add lines C21 through C23. Enter here and on the front of this form on line 16

D25 Exemption: Age 65 or over.

....................................... D25

Multiply the number in box 8, page 1, by $2,100

D26 Exemption: Blind.

...................................................... D26

Multiply the number in box 9, page 1, by $1,500

D27 Exemption: Dependents.

......................................... D27

Multiply the number in box 10, page 1, by $2,300

D28 Exemption: Qualifying parents and grandparents.

. D28

Multiply the number in box 11, page 1, by $10,000

D29 Total exemptions:

.................................................................................... D29

Add lines D25 through D28

D30 Multiply line D29 by the percentage on line B20, and enter the result ...............................................................................

D30

D31 Interest on U.S. obligations such as U.S. savings bonds and treasury bills included in the ARIZONA column .................

D31

D32 Arizona state lottery winnings included on line B15 in the ARIZONA column (up to $5,000 only) .....................................

D32

D33 U.S. Social Security or Railroad Retirement Act benefits included in your ARIZONA income ...........................................

D33

D34 Adjustment for I.R.C. §179 expense not allowed ...............................................................................................................

D34

D35 Other subtractions from income:

....................................................................

D35

See instructions and attach your own schedule

D36 Total:

......................................................................

D36

Add lines D30 through D35. Enter here and on the front of this form, line 17

E37 Last name(s) used in prior years –

if different from name(s) used in current year:

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.

AZ Form 140PY (2012)

ADOR 10149 (12)

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