Arizona Form 140et - Credit For Increased Excise Taxes - 2012

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FOR
ARIZONA FORM
CALENDAR YEAR
140ET
2012
Credit for Increased Excise Taxes
Check box 95 if amended for year 2012
95
Your First Name and Middle Initial
Last Name
Your Social Security No.
Enter
1
your
Spouse’s First Name and Middle Initial (if box 4 or 6 checked)
Last Name
Spouse’s Social Security No.
SSN(s).
1
Current Home Address - number and street, rural route
Apt. No.
Daytime Phone (with area code)
Home Phone (with area code)
2
94
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
City, Town or Post Office
State Zip Code
3
FILING STATUS (check the appropriate box):
4
Married filing joint claim
NAME OF QUALIFYING CHILD OR DEPENDENT
Head of household ........... ►
5
88
6
Married filing separate claim. Enter spouse’s name and Social Security No. above.
7
Single
81
80
WHO CAN USE FORM 140ET?
File Form 140ET only if you meet the following:
(a) You are not required to file an income tax return and you
(f) If you meet ALL of items (a) through (e), you may claim
do not qualify for the property tax credit on Form 140PTC.
this credit. Complete Form 140ET to figure your credit.
(b) You were an Arizona resident during 2012.
(g) Do not file Form 140ET if you are filing an income tax
(c) You are not claimed as a dependent by any other taxpayer.
return using Form 140, Form 140A, Form 140EZ or
(d) You were not sentenced for at least 60 days of 2012 to a
Form 140PY. You may claim this credit on those forms
county, state, or federal prison.
by completing the worksheet in the instructions for those
(e) Your federal adjusted gross income is:
forms.
• $25,000 or less if you are married filing a joint claim;
(h) Do not file Form 140ET if you are filing Form 140PTC. You
• $12,500 or less if single;
may claim this credit on Form 140PTC.
• $25,000 or less if you are filing as head of household;
• $12,500 or less if married filing a separate claim.
8 I have read the above information, and I certify that I qualify to claim this credit on this form ......................
8
YES
NO
9 List dependents (see instructions). If married filing a joint claim, you may list up to 2 dependents; all others may list up to 3.
FIRST NAME
LAST NAME
SOCIAL SECURITY NUMBER
A1
9
A2
9
A3
9
10 Total number of dependents entered on lines
A1 through
A3 .................................................................... 10
9
9
11 If you checked box 4, enter the number “2” here. If you checked box 5, 6, or 7, enter the number “1” here. 11
12 Add the amount on line 10 and line 11. Enter the total ................................................................................ 12
13 Multiply the amount on line 12 by $25. Enter the result ............................................................................... 13
14 Enter the smaller of line 13 or $100.00 ......................................................................................................... 14
A
A
Direct Deposit of Refund: Check box
if your deposit will be ultimately placed in a foreign account; see instructions.
14
14
ROUTING NUMBER
ACCOUNT NUMBER
C
Checking or
98
S
Savings
If this is your fi rst claim for 2012, STOP HERE, AND GO TO THE SIGNATURE BOX BELOW.
If this is an amended claim, complete lines 15 through 17, and check the box at the top of the form.
AMENDED
15 Enter the amount from line 5 of the worksheet on page 3 of the instructions ............................................... 15
16 Additional refund: If line 14 is larger than line 15, subtract line 15 from line 14 ........................................... 16
17 Amount to pay: If line 14 is less than line 15, subtract line 14 from line 15. Make check made payable to
Arizona Department of Revenue; include SSN on payment. Attach payment where indicated at left ...... 17
I have read this claim 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.
ADOR 10532 (12)
Mail this claim to: Arizona Department of Revenue, PO Box 52138, Phoenix, AZ, 85072-2138.
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