Form It1040x - Ohio Amended Individual Income Tax Return

IT1040X OHIO

Amended Individual Income Tax Return

(Rev. 12/04)

For fiscal year ending _________________________________ , 20 _____

Calendar Year

EPARTMENT

NLY

Filing Status:

(Check only one box in each column)

Your first name

Initial

Last name

Your social security number

Original

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Amended

If a joint return, spouse's first name

Initial

Last name

Spouse's social security number

Single

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

Married filing joint return

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

Home address (number and street)

Ohio county

Married filing separately

Ohio Public School District Number

City, town or post office, state and ZIP code

(for current address)

Have you moved since you filed your last tax return? If yes, check the box.

As Filed

As Amended

Ohio Residency Status:

Resident

Part-year Resident

Nonresident

(check only one box)

From __________/______ to __________/______

1 Federal Adjusted Gross Income .........................................................................

2 Schedule A Adjustment ....................................................................................

3 Ohio Adjusted Gross Income (Line 2 subtracted from or added to Line 1) ........

4 Personal and Dependency Exemptions ...............................................................................

5 Ohio Taxable Income (subtract Line 4 from Line 3) ............................................

6 Tax on line 5 (see tax tables) .............................................................................

7 Schedule B Credits (cannot exceed Line 6) .......................................................

8 Tax less Schedule B Credits (subtract Line 7 from Line 6) ................................

9 Exemption Credit ................................................................................................

10 Tax less Exemption Credit (subtract Line 9 from Line 8) ....................................

11 Joint Filing Credit ...............................................................................................

12 Tax less Joint Filing Credit (subtract Line 11 from Line 10) ................................

13 Schedule C, D, and E Credits ............................................................................

14 Ohio Income Tax (subtract Line 13 from Line 12) ..............................................

15 IT 2210 Interest/Penalty .........................................................................................

16 Unpaid Ohio Use Tax .........................................................................................

17 Total Ohio Tax (add lines 14, 15 and 16) ............................................................

18 Ohio Income Tax Withheld .................................................................................

19 Ohio Estimated Tax, IT 40P Payments and Credit Carryover .......................................

20 Refundable Credits .............................................................................................

21 Amount paid with Previously Filed Returns ........................................................

Total of Lines 18 through 21 .......................................................................................................................................

Overpayment shown on original return and on previously filed amended returns

(even if you have not yet received the refund)

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

Subtract Line 23 from Line 22 ....................................................................................................................................

If Line 24 is less than Line 17 (as amended), subtract Line 24 from Line 17 and enter the amount owed.

AMOUNT YOU OWE

25 Make your payment payable to Ohio Treasurer of State ..........................................

If Line 24 is greater than Line 17 (as amended), subtract Line 17 from Line 24 and

YOUR REFUND

Enter the Amount of your Refund ...................................................................................

If the balance due is less than $1.01 payment need not be made, and if the overpayment is less than $1.01 no refund will be issued.

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief

it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Date Rec'd.

Code

Interest

Your Signature

Date

Mail to:

Ohio Department of Taxation

Spouse's Signature (if filing joint, BOTH must sign)

Telephone Number (optional)

P.O. Box 1460

Columbus, OH 43216-1460