Form 104x - Amended Colorado Individual Income Tax Return - 2012 Page 3
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9Departmental Use Only
Form 104X
FORM 104X (12/14/12)
FORM 104X (12/14/12) Web
COLORADO DEPARTMENT OF REVENUE
COLORADO DEPARTMENT OF REVENUE
Amended Colorado Individual
Denver CO 80261-0005
Denver CO 80261-0005
(0015)
Income Tax Return
2012
Reason for amended return (mark one):
Investment credit carryback from tax year ending ________
- or -
Federal net operating loss carryback from tax year ending ________
Federal net capital loss carryback from tax year ending ________
Fiscal Year Ending
Protective claim, attach explanation
Other, attach explanation
_________ ,20 ____
Changing filing status
Changing residency status
Last Name
First Name And Initial
Date of Birth
Social Security Number
Deceased
Yourself
DD
MM
YYYY
Yes
Spouse, if joint
Yes
Mailing Address
Telephone Number
(
)
ZIP Code
Foreign Country (if applicable)
City
State
As Amended
1.
1
00
Enter Federal Taxable Income from 1040EZ line 6, 104A line 27, 1040 line 43 or 1040X line 5
Additions
2.
2
State Addback, enter the state income tax deduction from your federal form 1040 schedule A, line 5 (see instructions)
00
3.
Other Additions, explain (see instructions)
3
00
4.
4
00
Subtotal, add lines 1 through 3
Subtractions
5.
5
State Income Tax Refund from federal income tax form: enter $0 if filing 1040EZ or 1040A; 1040 line 10
00
6.
6
U.S. Government Interest
00
7.
Primary Taxpayer Pension/Annuity income
Deceased SSN:
7
00
8.
8
Spouse Pension/Annuity income
Deceased SSN:
00
9.
Colorado Source Capital Gain; 5-year assets acquired on or after 5/9/1994
9
00
10
Total Contribution $ __________________________
. Tuition Program Contribution: (see instructions)
Owner’s Name ____________________________
10
Owner’s SSN
00
_________________________
11
11
. Qualifying Charitable Contribution
00
Total Contributions $
12
12
. Qualified Reservation Income
00
13
13
. PERA/DPSRS Subtraction, for PERA contributions made in 1984–1986 or DPSRS contributions made in 1986
00
14.
14
Railroad Benefit Subtraction, tier I or II only
00
15.
15
Wildfire Mitigation Measures Subtraction
00
Other Subtractions, explain (see instructions) ____________________________________________
16.
16
00
17.
17
00
Subtotal, add lines 5 through 16
18.
18
00
Colorado Taxable Income, line 4 minus line 18
Tax, Prepayments and Credits: see 104 Booklet for full-year tax table and part-year PN Schedule
19.
19
Colorado Tax from tax table or 104PN line 36 (attach 104PN, if applicable)
00
Staple
20.
20
Alternative Minimum Tax from Form 104AMT
00
W-2,
W2G,
21.
21
00
Recapture of prior year credits
and
22.
22
1099
00
Subtotal, add lines 19 through 21
Forms
23.
23
Nonrefundable Credits from 104CR line 49, cannot exceed the sum of lines 19 and 20
00
Here
24.
24
Net Tax, subtract line 23 from line 22
(Only if
00
Colorado
25.
25
CO Income Tax Withheld from W-2s and 1099s. Staple only if line 25 is greater than $0.
00
tax
26.
Estimated Tax, enter the sum of payments and credits and amounts withheld from
withheld
26
nonresident real estate sales and partnership/S corp/fiduciary income
00
is
27.
27
reported
00
Refundable Credits from 104CR line 9
on the
28.
28
form)
00
Subtotal, add lines 25 through 27
29
. Federal Adjusted Gross Income from your federal income tax form: 1040EZ line 4;
29
1040A line 21; 1040 line 37
00
If you want the Department of Revenue to compute and mail your refund, or compute your balance due and mail a bill, stop
STOP!
here and leave lines 30 through 45 blank. If you want to compute the refund or balance due yourself, continue with line 30.
AMENDED
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