Arizona Form 140py - Part-Year Resident Personal Income Tax Return

Form 140PY (1999) Page

No. of months

List children and other dependents. If more space is needed, attach a separate sheet.

lived in your home

First name

Last name

Social security number

Relationship

in 1999

Enter total number of persons listed in A1 here and on the front of this form, box 10.

TOTAL

Enter the names of the dependents age 65 or over listed above who do not qualify as your dependent on your federal return:

List qualifying parents and ancestors. If more space is needed, attach a separate sheet. You cannot list the same person here and also on

line A1. For information on who is a qualifying parent or ancestor, see pages 4 and 5 of the instructions.

No. of months

First name

Last name

Social security number

Relationship

lived in your home

in 1999

Enter total number of persons listed in A4 here and on the front of this form, box 11.

TOTAL

Dates of Arizona residency: From

1999 FEDERAL

1999 ARIZONA

Amounts only

Amounts from federal return

List other state(s) of residency

Wages, salaries, tips, etc. ..........................................................................................................................

Interest .......................................................................................................................................................

Dividends ...................................................................................................................................................

B10 Arizona income tax refunds .......................................................................................................................

B10

B11 Alimony received .......................................................................................................................................

B11

B12 Business income or (loss) from federal Schedule C .................................................................................

B12

B13 Gain or (loss) from federal Schedule D......................................................................................................

B13

B14 Rents, royalties, partnerships, estates, trusts, small business corporations, from federal Schedule E ....

B14

B15 Other income reported on your federal return ...........................................................................................

B15

B16 Total income. Add lines B7 through B15 ..................................................................................................

B16

B17

B17 Total IRA deduction....................................................................................................................................

B18

B18 Other federal adjustments. Attach your own schedule ..............................................................................

B19

B19 Total adjustments. Add lines B17 and B18 .............................................................................................

B20 Federal adjusted gross income. Subtract line B19 from line B16 in FEDERAL Column ...........................

B20

B21 Arizona income. Subtract line B19 from line B16 in ARIZONA Column. Enter here and on the front of this form line 15 ......................

B22 Arizona percentage. Divide line B21 by line B20 and enter the result (not over 100%) ........................................................................

C23 Early withdrawal of Arizona Retirement System contributions ................................................................................................................

C23

C24 Other additions to income. See instructions and attach your own schedule ...........................................................................................

C24

C25

C25 Total. Add lines C23 and C24. Enter here and on the front of this form, line 16......................................................................................

D26 Exemption: Age 65 or over. Multiply number in box 8, page 1, by $2,100 ...............................................

D26

D27 Exemption: Blind. Multiply number in box 9, page 1, by $1,500 ................................................................

D27

D28 Exemption: Dependents. Multiply number in box 10, page 1, by $2,300 ..................................................

D28

D29 Exemption: Qualifying parents and ancestors. Multiply number in box 11, page 1, by $10,000 ...............

D29

D30

D30 Total exemptions. Add lines D26 through D29 ..........................................................................................

D31

D31 Multiply line D30 by percentage on line B22 and enter the result............................................................................................................

D32

D32 Interest on U.S. obligations, such as U.S. Savings Bonds and Treasury Bills included in the ARIZONA column ..................................

D33

D33 Arizona state lottery winnings included on line B15 in ARIZONA column (up to $5,000 only) ................................................................

D34

D34 U.S. social security or Railroad Retirement Act benefits included in your ARIZONA income .................................................................

D35

D35 Alternative fuel vehicles and refueling equipment ...................................................................................................................................

D36 Other subtractions. See instructions and attach your own schedule. .................................................................................................. . ..

D36

D37 Total. Add lines D31 through D36. Enter here and on the front of this form, line 19 ..............................................................................

D37

E38 Last name(s) used in prior years if different from name(s) used in current year.

I have read this return 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

Please

Sign

Spouse's occupation

Spouse's signature

Date

Here

Firm's name (preparer's if self-employed)

Preparer's signature

Paid

Preparer's

Preparer's TIN

Preparer's address

Information

Date

If you are sending a payment with this return, mail to: Arizona Department of Revenue, PO Box 52016, Phoenix AZ 85072-2016.

If you are expecting a refund, or owe no tax, or owe tax but are not sending a payment, mail to: Arizona Department of Revenue, PO Box 52138, Phoenix AZ 85072-2138.

ADOR 06-0069 (99)

Arizona Form 140py - Part-Year Resident Personal Income Tax Return - 1999 Page 2

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