Form 1040x - Amended U.s. Individual Income Tax Return
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21040X
Department of the Treasury—Internal Revenue Service
Amended U.S. Individual Income Tax Return
OMB No. 1545-0074
(Rev. December 2014)
Information about Form 1040X and its separate instructions is at
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This return is for calendar year
2014
2013
2012
2011
Other year. Enter one: calendar year
or fiscal year (month and year ended):
Your social security number
Your first name and initial
Last name
Spouse’s social security number
If a joint return, spouse’s first name and initial
Last name
Current home address (number and street). If you have a P.O. box, see instructions.
Apt. no.
Your phone number
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
Foreign postal code
Foreign country name
Foreign province/state/county
Amended return filing status. You must check one box even if you are not changing
Full-year coverage.
your filing status. Caution. In general, you cannot change your filing status from joint to
If all members of your household have full-
separate returns after the due date.
year minimal essential health care coverage,
check "Yes." Otherwise, check "No."
Single
Married filing separately
(See instructions.)
Qualifying widow(er)
Head of household (If the qualifying person is a child but not
your dependent, see instructions.)
Married filing jointly
Yes
No
A. Original amount
B. Net change—
Use Part III on the back to explain any changes
C. Correct
or as previously
amount of increase
adjusted
or (decrease)—
amount
Income and Deductions
(see instructions)
explain in Part III
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Adjusted gross income. If net operating loss (NOL) carryback is
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included, check here .
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2
2
Itemized deductions or standard deduction
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Subtract line 2 from line 1
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4
Exemptions. If changing, complete Part I on page 2 and enter the
amount from line 29 .
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4
5
Taxable income. Subtract line 4 from line 3 .
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Tax Liability
Tax. Enter method(s) used to figure tax (see instructions):
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6
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Credits. If general business credit carryback is included, check
here .
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8
Subtract line 7 from line 6. If the result is zero or less, enter -0- .
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Health care: individual responsibility (see instructions) .
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Other taxes .
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Total tax. Add lines 8, 9, and 10
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11
Payments
12
Federal income tax withheld and excess social security and tier 1 RRTA
tax withheld (if changing, see instructions) .
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Estimated tax payments, including amount applied from prior year’s
return .
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Earned income credit (EIC) .
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Refundable credits from:
Schedule
8812 Form(s)
2439
4136
5405
8801
8812 (2011)
8839
8863
8885
15
8962 or
other (specify):
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Total amount paid with request for extension of time to file, tax paid with original return, and additional
tax paid after return was filed
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Total payments. Add lines 12 through 16
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Refund or Amount You Owe (
Note. Allow up to 16 weeks for Form 1040X to be processed.)
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18
Overpayment, if any, as shown on original return or as previously adjusted by the IRS .
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19
Subtract line 18 from line 17 (If less than zero, see instructions) .
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19
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Amount you owe. If line 11, column C, is more than line 19, enter the difference
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21
If line 11, column C, is less than line 19, enter the difference. This is the amount overpaid on this return
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Amount of line 21 you want refunded to you .
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Amount of line 21 you want applied to your
(enter year):
estimated tax .
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Complete and sign this form on Page 2.
1040X
For Paperwork Reduction Act Notice, see instructions.
Form
(Rev. 12-2014)
Cat. No. 11360L
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