Form D-400x - Amended Individual Income Tax Return

Form D-400x - Amended Individual Income Tax Return - 2014 Page 3

Last Name (First 10 Characters)

Tax Year

Your Social Security Number

Page 3

2014

D-400X

Be sure to sign and date your return below.

Explanation of Changes

Give the reason for each change. Attach all supporting forms and schedules for the items changed. Be sure to include your name and social

security number on any attachments. If the changes are also applicable to your federal return, include a copy of Federal Form 1040X. If

there was a change to wages or State withholding, be sure to include corrected Forms W-2 or 1099. Refunds will not be processed without

a complete explanation of changes and required attachments.

I certify that, to the best of my knowledge, this return is accurate and complete.

If prepared by a person other than taxpayer, this certification is based on all

information of which the preparer has any knowledge.

Your Signature

Date

Paid Preparer’s Signature

Spouse’s Signature (If filing joint return, both must sign.)

Date

Preparer’s FEIN, SSN, or PTIN

Home Telephone Number (Include area code.)

Preparer’s Telephone Number (Include area code.)

Mail all amended returns, payment for the amount shown due on line 27, and Form D-400V Amended to:

N.C. DEPARTMENT OF REVENUE, P.O. BOX 25000, RALEIGH, NC 27640-0640

Form D-400x - Amended Individual Income Tax Return - 2014 Page 3