Arizona Form 140a - Resident Personal Income Tax Return (Short Form) - 2012 Page 2

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Your Name (as shown on page 1)

Your Social Security No.

PART A: Dependents, Qualifying Parents and Grandparents -

do not list yourself or spouse

A1 List children and other dependents. 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. See

Return to Page 1

page 6 of the instructions.

MAILING INSTRUCTIONS

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

Mail your return to the P. O.

Box listed below for

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

barcode forms (P. O. Box

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

29204 or 29205).

qualifying parent or grandparent, see page 6 of the instructions.

NO. OF MONTHS LIVED

Using the correct P. O. Box

FIRST AND LAST NAME

SOCIAL SECURITY NO.

RELATIONSHIP

IN YOUR HOME IN 2012

speeds up the handling of

your return.

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

Return to Page 1

PART B: 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 also sending a payment, mail to Arizona Department of Revenue, PO Box 52016, Phoenix, AZ 85072-2016 (PO Box 29204, Phoenix, AZ 85038-9204 if your return has a barcode).

If you are not sending a payment, mail to Arizona Department of Revenue, PO Box 52138, Phoenix, AZ 85072-2138 (PO Box 29205, Phoenix, AZ 85038-9205 if your return has a barcode).

ADOR 10414 (12)

AZ Form 140A (2012)

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