
88
81 80
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
NO TAPE.
Part-Year Resident Personal Income Tax Return
ARIZONA FORM
140PY
8 Age 65 or over (you and/or spouse)
9 Blind (you and/or spouse)
10 Dependents. From page 2, line A2 – do not include self or spouse.
11 Qualifying parents and grandparents from page 2, line A5.
12-13 Residency Status (check one): 12
Part-Year Resident Other than Active Military 13
Part-Year Resident Active Military
14 Federal adjusted gross income (from your federal return) ............................................................... 14 00
15 Arizona income (from page 2, line B19) .................................................................................................................................. 15 00
16 Additions to income (from page 2, line C24) ........................................................................................................................... 16 00
17 Subtractions from income (from page 2, line D36) .................................................................................................................. 17 00
18 Arizona adjusted gross income: Add lines 15 and 16 then subtract line 17 .......................................................................... 18 00
19 Deductions. Check box and enter amount. See instructions, page 16 ............... 19I
ITEMIZED 19S
STANDARD 19 00
20 Personal exemptions. See page 16 of the instructions ............................................................................................................ 20 00
21 Arizona taxable income: Subtract lines 19 and 20 from line 18. If less than zero, enter zero ....................................................... 21 00
22 Compute the tax using Tax Table X or Y ............................................................................................................................. 22 00
23 Tax from recapture of credits from Arizona Form 301, Part II, line 35 ................................................................................ 23 00
24 Subtotal of tax: Add lines 22 and 23 ...................................................................................................................................... 24 00
25 Family income tax credit from worksheet on pages 17 and 18 of the instructions ............................................................. 25 00
26 Credits from Arizona Form 301, Part II, line 68, or Forms 310, 321, 322 and 323, if Form 301 is not required ................. 26 00
27 Credit type: Enter form number of each credit claimed ..............
27
3 3 3 3
28 Clean Elections Fund Tax Credit for donations made prior to August 2, 2012 (from worksheet on page 20 of the instructions) 28 00
29 Balance of tax: Subtract lines 25, 26 and 28 from line 24. If the sum of lines 25, 26 and 28 is more than line 24, enter zero ............ 29 00
30 Arizona income tax withheld during 2012 ........................................................................................................................... 30 00
31 Arizona estimated tax payments for 2012 .......................................................................................................................... 31 00
32 2012 Arizona extension payment (Form 204) ..................................................................................................................... 32 00
33 Increased Excise Tax Credit: From worksheet on page 20 of the instructions ........................................................................... 33 00
34 Other refundable credits: Check the box(es) and enter the amount ......................... 341
Form 308-I 342
Form 342 34 00
35 Total payments/refundable credits: Add lines 30 through 34 ............................................................................................. 35 00
36 TAX DUE: If line 29 is larger than line 35, subtract line 35 from line 29, and enter amount of tax due. Skip lines 37, 38 and 39 ........... 36 00
37 OVERPAYMENT: If line 35 is larger than line 29, subtract line 29 from line 35, and enter amount of overpayment ........................... 37 00
38 Amount of line 37 to be applied to 2013 estimated tax ....................................................................................................... 38 00
39 Balance of overpayment: Subtract line 38 from line 37 ........................................................................................................... 39 00
40 - 49 Voluntary Gifts to:
50 Voluntary Political Gift (check only one): 501
Americans Elect 502
Democratic 503
Green 504
Libertarian 505
Republican
51 Estimated payment penalty and MSA withdrawal penalty .................................................................................................. 51 00
52 Check applicable boxes .... 521
Annualized/Other 522
Farmer or Fisherman 523
Form 221 attached 524
MSA Penalty
53 Total of lines 40 through 49 and 51 .................................................................................................................................... 53 00
54 REFUND: Subtract line 53 from line 39. If less than zero, enter amount owed on line 55 .............................................................. 54 00
98
Direct Deposit of Refund: Check box 54A if your deposit will be ultimately placed in a foreign account; see instructions ........54A
ROUTING NUMBER ACCOUNT NUMBER
C Checking or
S Savings
55 AMOUNT OWED: Add lines 36 and 53. Make check payable to Arizona Department of Revenue; include SSN on payment ........ 55 00
Aid to Education .................................
40 00
Arizona Wildlife ...................................
41 00
Child Abuse Prevention ......................
42 00
Domestic Violence Shelter .................
43 00
I Didn’t Pay Enough Fund...................
44 00
National Guard Relief Fund ................
45 00
Neighbors Helping Neighbors.............
46 00
Special Olympics ................................
47 00
Veterans’ Donations Fund ..................
48 00
Political Gift.........................................
49 00
Your First Name and Middle Initial Last Name Your Social Security No.
1
Spouse’s First Name and Middle Initial (if box 4 or 6 checked) Last Name Spouse’s Social Security No.
1
Current Home Address - number and street, rural route Apt. No. Daytime Phone (with area code) Home Phone (with area code)
94
2
City, Town or Post Office State Zip Code
3
OR FISCAL YEAR BEGINNING
MMDDYYYY
AND ENDING
MMDDYYYY
.
FOR
CALENDAR YEAR
2012
82F
Check box 82F if filing under extension
ADOR 10149 (12)
Enter
your
SSN(s).
Ð
Enter the number claimed. Do not put a check mark.
FILING STATUS
EXEMPTIONS
STAPLE PAYMENT HERE. NO TAPE.
Place any required federal and AZ schedules or other documents after Form 140PY page 2; staple to upper left corner.
4 Married filing joint return
5 Head of household ......►
NAME OF QUALIFYING CHILD OR DEPENDENT
6 Married filing separate return. Enter spouse’s name and Social Security No. above.
7 Single