Form Ia 1040x - Amended Iowa Individual Income Tax Return
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4IA 1040X
For fiscal year beginning ___/___/_____ and ending ___/___/_____
Reset Form
Print Form
STEP 1
Amended Iowa Individual Income Tax Return
A.
Your last name
Your first name/middle initial
Social Security Number
•
B.
Spouse’s last name
Spouse’s first name/middle initial Social Security Number
•
Current Mailing address (number and street or PO Box):
Residence on 12/31 of
For Calendar Year
•
Check this box if you or your
year being amended
•
spouse were 65 or older at the end
__ __ __ __
County No: _____________
•
City, State, ZIP
of the tax year.
•
Sch. Dist. No: ___________
•
Reason for
STEP 2 Filing Status: Mark correct status.
Amendment:
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1
Single: Were you claimed as a dependent on another person’s Iowa return for the year being amended?
YES
NO
NONNO
Net Operating Loss
2
Married filing a joint return.
Federal Audit
3
Married filing separately on this combined return. Spouse use column B.
Protective Claim
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4
Married filing separate returns. Spouse’s name:
SSN:
Net Income: $
Other
5
Head of household with qualifying person.
If qualifying person is not claimed as a dependent on this return, enter the person’s name and Social Security Number here.
Provide detailed
explanation on back.
6
Qualifying widow(er) with dependent child.
Name:
SSN:
B. Spouse (Filing Status 3 ONLY)
A. You or Joint
STEP 3 Corrected Exemptions
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X $ 40 = $
a. Personal Credit:
X $ 40 = $
Col. A: Enter 1 (enter 2 if filing status 2 or 5); Col. B: Enter 1 if filing status 3
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X $ 20 = $
X $ 20 = $
b. Enter 1 for each person who is 65 or older and/or 1 for each person who is blind..............
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X $ 40 = $
c. Dependents: Enter 1 for each dependent ...................................................................
X $ 40 = $
d. Enter first names of dependents here: ____________________________________
e. TOTAL $
TOTAL $
STEP 4
B. Spouse/Status 3
A. You or Joint
Corrected
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1. Gross Income ....................................................................................................................................................................... 1. ______________ .00 ________________ .00
Taxable
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2. Adjustments to Income ........................................................................................................................................................ 2. ______________ .00 ________________ .00
Income
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3. Net Income. Subtract line 2 from line 1. ............................................................................................................................ 3. ______________ .00 ________________ .00
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4. Addition for Federal Taxes ................................................................................................................................................ 4. ______________ .00 ________________ .00
5. Total. Add lines 3 and 4. .................................................................................................................................................... 5. ______________ .00 ________________ .00
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6. Deduction for Federal Taxes ............................................................................................................................................. 6. ______________ .00 ________________ .00
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7. Balance. Subtract line 6 from line 5. ................................................................................................................................. 7. ______________ .00 ________________ .00
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8. Deduction: Itemized / Standard ....
Itemized .......
Standard .......................................................................... 8. ______________ .00 ________________ .00
9. Taxable Income. Subtract line 8 from line 7. ..................................................................................................................... 9. ______________ .00 ________________ .00
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STEP 5
10. Tax or Alternative Tax ....................................................................................................................................................... 10. ______________ .00 ________________ .00
Figure
11. Iowa Lump Sum/Minimum Tax .......................................................................................................................................... 11. ______________ .00 ________________ .00
Your Tax
12. Total Tax. Add lines 10 and 11. ........................................................................................................................................ 12. ______________ .00 ________________ .00
and
Credits
13. Total of Exemption Credits, Earned Income Tax Credit (for years 2006 and prior), and Tuition and Textbook Credit ... 13. ______________ .00 ________________ .00
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14. Balance. Subtract line 13 from line 12. If less than zero, enter zero. ............................................................................... 14. ______________ .00 ________________ .00
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15. Credit for Nonresident or Part-Year Resident. Attach IA 126. .......................................................................................... 15. ______________ .00 ________________ .00
16. Balance. Subtract line 15 from line 14. If less than zero, enter zero. ............................................................................... 16. ______________ .00 ________________ .00
17. Other Iowa Credits. Attach IA 148 Tax Credits Schedule. ................................................................................................ 17. ______________ .00 ________________ .00
18. Balance. Subtract line 17 from line 16. If less than zero, enter zero. ............................................................................... 18. ______________ .00 ________________ .00
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19. School District Surtax/Emergency Medical Services Surtax ............................................................................................ 19. ______________ .00 ________________ .00
20. Contributions from Original Return .................................................................................................................................... 20. ______________ .00 ________________ .00
21. Total Tax. Add lines 18, 19, and 20. ................................................................................................................................. 21. ______________ .00 ________________ .00
22. Total. Add columns A & B, line 21, and enter here. .............................................................................................................................................. 22. ________________ .00
23. Total Credits B & A from Step 9 of the IA 1040. See instructions. ....................................................................................................................... 23. ________________ .00
STEP 6
Refund
24. Tax amount previously paid .................................................................................................................................................................................. 24. ________________ .00
or
25. Total credits and payments. Add lines 23 and 24. ................................................................................................................................................. 25. ________________ .00
Amount
26. Overpayment shown on previous filing .................................................................................................................................................................. 26. ________________ .00
You Owe
27. Subtract line 26 from line 25. Enter here. .............................................................................................................................................................. 27. ________________ .00
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28. If line 27 is more than line 22, subtract line 22 from line 27. This is the REFUND amount. ............................................................. REFUND
28. ________________ .00
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29. If line 27 is less than line 22, subtract line 27 from line 22. This is the AMOUNT OF TAX YOU OWE. .............................................................. 29. ________________ .00
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30. Penalty and Interest. See instructions.
30a. Penalty__________
+30 b. Interest__________ ................ 30. ________________ .00
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31. TOTAL AMOUNT NOW DUE. Add lines 29 and 30 and enter here. ....................................................................................................PAY
31. ________________ .00
I (We), the undersigned, declare under penalty of perjury that I (we) have examined this return and attachments, and, to the best of my (our) knowledge and belief, it is a true, correct,
and complete return. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Your Signature: ____________________________________________ Date: _________
Spouse’s Signature: ________________________________________ Date: _________
Daytime Telephone Number:________________________________________________
*1241122019999*
Preparer’s Signature:_______________________________________ Date: ________
Firm: ________________________________________ Phone:
Address: ______________________________________________________________
ID#: __________________________________________________________________
41-122a (09/07/12)
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