Arizona Form 140py - Part-Year Resident Personal Income Tax Return - 2004 Page 2

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Form 140PY (2004) Page 2

ADOR 91-0069 (04) 1250

A1 List children and other dependents. Do not list yourself or spouse. If more space is needed, attach a separate sheet.

NO. OF MONTHS LIVED

FIRST AND LAST NAME

SOCIAL SECURITY NO.

RELATIONSHIP

IN YOUR HOME IN 2004

A2 Enter total number of persons listed in A1 here and on the front of this form, box 10 ....................................................... TOTAL

A3 Enter the names of the dependents listed above who do not qualify as your dependent on your federal return:

A4 List qualifying parents and ancestors of your parents. If more space is needed, attach a separate sheet. You cannot list the same person here and also on

A T T E N T I O N

line A1. For information on who is a qualifying parent or ancestor of your parents, see page 5 of the instructions.

NO. OF MONTHS LIVED

* You are NOT able to use this form if you are claiming exemption(s) for Qualifying Parents.

FIRST AND LAST NAME

SOCIAL SECURITY NO.

RELATIONSHIP

IN YOUR HOME IN 2004

* Click here to go to a fillable form.

* The linked form is fillable but not barcoded.

* You will need to re-enter any data that you have entered on this form.

A5 Enter total number of persons listed in A4 here and on the front of this form, box 11. ...................................................... TOTAL

B6 Dates of AZ residency: From/To: ____________________________________________________

2004 FEDERAL

2004 ARIZONA

Amount from federal return

Amount only

List other state(s) of residency: ____________________________________________________

B7 Wages, salaries, tips, etc. ...................................................................................................................

B8 Interest.................................................................................................................................................

B9 Dividends .............................................................................................................................................

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

B10

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

B11

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

B12

B13 Gains (or losses) 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 Federal adjustments. Attach your own schedule ................................................................................

B17

B18 Federal adjusted gross income. Subtract line B17 from line B16 in the FEDERAL column ...............

B18

B19 Arizona income: Subtract line B17 from line B16 in the ARIZONA column. Enter here and on the front of this form, line 15 ....

B19

B20 Arizona percentage: Divide line B19 by line B18, and enter the result (not over 100%)..............................................................

B20

C21 Early withdrawal of Arizona Retirement System contributions......................................................................................................

C21

C22 Total depreciation included in Arizona gross income ....................................................................................................................

C22

C23 Other additions to income. See instructions and attach your own schedule................................................................................

C23

C24 Total: Add lines C21 through C23. Enter here and on the front of this form on line 16...............................................................

C24

D25 Exemption: Age 65 or over. Multiply the number in box 8, page 1, by $2,100...................................

D25

D26 Exemption: Blind. Multiply the number in box 9, page 1, by $1,500 ..................................................

D26

D27 Exemption: Dependents. Multiply the number in box 10, page 1, by $2,300.....................................

D27

D28 Exemption: Qualifying parents and ancestors. Multiply the number in box 11, page 1, by $10,000..

D28

D29 Total exemptions: Add lines D25 through D28....................................................................................

D29

D30 Multiply line D29 by the percentage on line B20, and enter the result..........................................................................................

D30

D31 Interest on U.S. obligations such as U.S. savings bonds and treasury bills included in the ARIZONA column............................

D31

D32 Arizona state lottery winnings included on line B15 in the ARIZONA column (up to $5,000 only) ................................................

D32

D33 U.S. Social Security or Railroad Retirement Act beneﬁ ts included in your ARIZONA income ......................................................

D33

D34 Construction of an energy efﬁ cient residence. See page 10 of instructions. Enter number D34a

, then amount...........

D34

D35 Other subtractions from income. See instructions and attach your own schedule ......................................................................

D35

D36 Total: Add lines D30 through D35. Enter here and on the front of this form, line 19...................................................................

D36

E37 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.

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YOUR SIGNATURE

DATE

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SPOUSE’S SIGNATURE

DATE

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PAID PREPARER’S SIGNATURE

FIRM’S NAME (PREPARER’S IF SELF-EMPLOYED)

PAID PREPARER’S TIN

DATE

PAID PREPARER’S ADDRESS

If you are sending a payment with this return, mail to Arizona Department of Revenue, PO Box 29204, Phoenix, AZ, 85038-9204.

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 29205, Phoenix, AZ, 85038-9205.