Fillable Form 140et - Credit For Increased Excise Taxes

For

caLeNDar year

Arizona Form 140ET

Credit for Increased Excise Taxes

2013

Check box 95 if amended for year 2013

your First Name and middle Initial

Last Name

your social security No.

Enter

your

spouse’s First Name and middle Initial (if box 4 or 6 checked)

Last Name

spouse’s social security No.

SSN(s).

current Home address - number and street, rural route

apt. No.

Daytime Phone (with area code)

city, town or Post office

state

ZIP code

REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

FILINg STATUS (check the appropriate box):

married filing joint claim

Head of household –

enter name of qualifying child or dependent on next line:

81 PM

80 RCVD

married filing separate claim. enter spouse’s name and social security No. above.

single

WHO CAN USE FORM 140ET? File Form 140ET only if you meet the following:

(a) You are not required to file an income

(e) Your federal adjusted gross income is:

(g) Do not file Form 140ET if you are filing an

tax return and you do not qualify for the

• $25,000 or less if you are married filing a

income tax return using Form 140, Form

property tax credit on Form 140PTC.

joint claim;

140A, Form 140EZ or Form 140PY. You

(b) You were an Arizona resident during 2013.

• $12,500 or less if single;

may claim this credit on those forms by

• $25,000 or less if you are filing as head of

completing the worksheet in the instructions

other taxpayer.

household;

for those forms.

(d) You were not sentenced for at least 60 days

• $12,500 or less if married filing a separate

(h) Do not file Form 140ET if you are filing

of 2013 to a county, state, or federal prison.

claim.

Form 140PTC. You may claim this credit on

(f) If you meet ALL of items (a) through (e),

Form 140PTC.

you may claim this credit. Complete Form

140ET to figure your credit.



8 I have read the above information, and I certify that I qualify to claim this credit on this form . ....................... 8

YES

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

10 total number of dependents entered on lines

a1 through

a3 . ..................................................................... 10

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



Direct Deposit of Refund: Check box

if your deposit will be ultimately placed in a foreign account; see instructions.

routING Number

accouNt Number



checking or



savings

If this is your first claim for 2013, STOP HERE, AND gO TO THE SIgNATURE BOX BELOW.

If this is an amended claim, complete lines 15 through 17, and check box 95 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 (PaID PreParer’s, IF seLF-emPLoyeD)

PaID PreParer’s street aDDress

PaID PreParer’s tIN

PaID PreParer’s cIty

state

ZIP coDe

PaID PreParer’s PHoNe No.

Mail this claim to: Arizona Department of Revenue, PO Box 52138, Phoenix, AZ, 85072-2138.

aDor 10532 (13)

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Form 140et - Credit For Increased Excise Taxes - 2013

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