Arizona Form 140nr - Nonresident Personal Income Tax Return - 2011 Page 3

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Your Name (as shown on page 1)

Your Social Security No.

PART A: Dependents - 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 2011

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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:

PART B: Arizona Percent of Total Income

B4 Check box B4 if married and you are the spouse of an active duty military member

2011 FEDERAL

2011 ARIZONA

Amount from Federal Return

Source Amount Only

who qualifies for relief under the Military Spouses Residency Relief Act ...........................B4

B5 Wages, salaries, tips, etc .............................................................................................................

B6 Interest ........................................................................................................................................

B7 Dividends .....................................................................................................................................

B8 Arizona income tax refunds .........................................................................................................

B9 Business income (or loss) from federal Schedule C ...................................................................

B10 Gains (or losses) from federal Schedule D .................................................................................

B10

B11 Rents, royalties, partnerships, estates, trusts, small business corporations

.....

B11

from federal Schedule E

B12 Other income reported on your federal return .............................................................................

B12

B13 Total income:

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

B13

Add lines B5 through B12

B14 Other federal adjustments.

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

B14

Attach your own schedule

B15 Federal adjusted gross income.

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

B15

Subtract line B14 from line B13 in the FEDERAL column

B16 Arizona income:

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

B16

Subtract line B14 from line B13 in the ARIZONA column. Enter here and on the front of this form on line 15

B17 Arizona percentage:

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

B17

Divide line B16 by line B15, and enter the result (not over 100%)

PART C: Additions to Income

C18 I.R.C. §179 expense in excess of allowable amount.

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

C18

Also see the instructions for line D30

C19 Total depreciation included in Arizona gross income ...........................................................................................................

C19

C20 Other additions to income.

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

C20

See instructions and attach your own schedule

C21 Total: Add lines C18 through C20.

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

C21

Enter here and on the front of this form on line 16

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PART D: Subtractions from Income

D22 Exemption: Age 65 or over.

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

D22

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

D23 Exemption: Blind.

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

D23

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

D24 Exemption: Dependents.

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

D24

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

D25 Total exemptions:

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

D25

Add lines D22 through D24

D26 Multiply line D25 by the percentage on line B17, and enter the result ................................................................................

D26

D27 Interest on U.S. obligations such as U.S. savings bonds and treasury bills included in the ARIZONA column ..................

D27

D28 Arizona state lottery winnings included on line B12 in the ARIZONA column (up to $5,000 only) ......................................

D28

D29 Agricultural crops contributed to Arizona charitable organizations ......................................................................................

D29

D30 Adjustment for I.R.C. §179 expense not allowed ...............................................................................................................

D30

D31 Other subtractions from income.

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

D31

See instructions and attach your own schedule

D32 Total: Add lines D26 through D31.

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

D32

Enter here and on the front of this form, line 17

Part E: Last Name(s) Used in Prior Years

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

E33

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 10177 (11)

AZ Form 140NR (2011)

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