Arizona Nonresident Personal Income Tax Return Form

A foreign/nonresident individual is subject to the State of Arizona’s tax collection if said individual’s income is derived from Arizona sources.Download

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81	80	
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.	
NO TAPE.
ADOR 10177 (12)	
Nonresident Personal Income Tax Return	ARIZONA FORM
140NR
 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 .
 11-13  Residency Status (check one):  11	
…	 Nonresident   12	…	 Nonresident Active Military    13	…	 Composite Return
  14  Federal adjusted gross income 	
(from your federal return )	 ...............................................................  14	 00	
 15 Arizona income 	(from page 2, line B16)	 .......................................................................\
....................................................... ...  15	 00	
 16  Additions to income 	(from page 2, line C21)	 .......................................................................\
...................................................   16	 00	
 17  Subtractions from income 	(from page 2, line D32)	 ........................................................................\
.........................................  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 13	 ...............  	19I…	 ITEMIZED   	19S…	 STANDARD 19	 00	
  20  Personal exemptions.  	See page 13 of the instructions	 ........................................................................\
...................................   20	 00	
 21  Arizona taxable income:  	Subtract lines 19 and 20 from line 18	 .......................................................................\
........................   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  Credits from Arizona Form 301, Part II, line 68, or Forms 321, 322 and 323 if Form 301 is not required  .........................  25	 00	
 26  Credit type:  	Enter form number of each credit claimed	 ..............  26	3	3	3	3	
 
27  Clean Elections Fund Tax Credit for donations made prior to August 2, 2012 (	from worksheet on page 16 of the instructions )	  27	 00	
  28  Balance of tax:  	Subtract lines 25 and 27 from line 24.  If the sum of lines 25 and 27 is more th\
an line 24,  enter zero	 .....................  28	 00	
 29  Arizona income tax withheld during 2012 ........................................................................\
..................................................   29	 00	
 30  Arizona estimated tax payments for 2012 ........................................................................\
.................................................   30	 00	
 31  2012 Arizona extension payment (Form 204) ........................................................................\
............................................   31	 00	
 32  Other refundable credits:  Check the box(es) and enter the amount  .........................  	321…	Form 308-I   	322…	Form 342 32 	00	
 33  Total payments/refundable credits:  	Add lines 29 through 32	 .......................................................................\
.....................   33	 00	
 34  TAX DUE:  	If line 28 is larger than line 33,  subtract line 33 from line 28, and  enter amount of tax due. Skip lines 35, 36 and 37	 ..........  34	 00	
 35  OVERPAYMENT:  	If line 33 is larger than line 28,  subtract line 28 from line 33, and  enter amount of overpayment	 ..........................  35	 00	
 36  Amount of line 35 to be applied to 2013 estimated tax ........................................................................\
..............................   36	 00	
 37  Balance of overpayment:  	Subtract line 36 from line 35	 ........................................................................\
..................................   37	 00	
  38 - 47 Voluntary Gifts to:
  48  Voluntary Political gift 	
(check only one ):  	481…	Americans Elect  	482…	Democratic  	483…	Green  	484…	Libertarian  	485…	Republican	
 49  Estimated payment penalty and MSA withdrawal penalty ........................................................................\
.........................   49	 00	
 50  Check applicable boxes ....  	501…	Annualized/Other   	502…	Farmer or Fisherman   	503…	Form 221 attached   	504…	MSA Penalty	
 51  Total of lines 38 through 47 and 49 ........................................................................\
...........................................................   51	 00	
 52  REFUND:  	Subtract line 51 from line 37.  If less than zero, enter amount owed on line 53	 .............................................................   52	 00	
98
Direct Deposit of Refund:  Check box 	52A if your deposit will be ultimately placed in a  foreign account; see instructions . ......	52A…	 ROUT NG NUMBER  ACCOUNT NUMBER	C … Checking or
S … Savings
  53  AMOUNT OWED:  	Add lines 34 and 51.   Make check payable to Arizona Department of Revenue;  include SSN on payment	 ........  53	 00	
Aid to Education .................................	38	00	Arizona Wildlife ...................................	39	00	
Child Abuse  Prevention ......................	40	00	Domestic Violence Shelter .................	41	00	
I Didn’t Pay Enough Fund...................	42	00	National Guard Relief Fund ................	43	00	
Neighbors Helping Neighbors.............	44	00	Special Olympics ................................	45	00	
Veterans’ Donations Fund ..................	46	00	Political Gift.........................................	47	00	
FILING STATUS
EXEMPTIONS	
Ð  
Enter the number claimed.  Do not put a check mark. FOR
CALENDAR YEAR	
2012	OR FISCAL YEAR BEGINNING  	MMDDYYYY	  AND ENDING  	MMDDYYYY	   66	
82F	Check box 82F if  filing under extension	
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
 4 	 Married filing joint return
  5 
 Head of household .......... ► 	NAME OF QUALIFY NG CH LD OR DEPENDENT	
 6 	 Married filing separate return.	  Enter spouse’s name and Social Security No. above.
  7 	
 Single	
Enter 
your
SSN(s).	
Place any required federal and AZ schedules or other documents after Form 140NR page 2; staple to upper left corner.
STAPLE  PAYMENT  HERE.    NO TAPE.

2012 FEDERAL  2012 ARIZONA  Amount from Federal Return  Source Amount Only	
ADOR 10177 (12)  AZ Form 140NR (2012)  Page 2 of 2
PART A:  Dependents - do not list yourself or spouse
 A1 List children and other dependents.  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 2012	
 A2 Enter total number of persons listed in A1 here and on the front of this form, box 10 ............................................ TOTAL A2
 A3 a  Enter the names of the dependents listed above who do not qualify as your dependent on your federal return:
   
  b Enter dependents listed above who were not claimed on your federal return due to education credits:
   
PART B:  Arizona Percent of Total Income
 B4 Check box B4 if married and you are the spouse of an active duty military member
who qualifies for relief under the Military Spouses Residency Relief Act .......................B4	
…	
 B5  Wages, salaries, tips, etc .........................................................................................................  B5	 00 00	
 B6 Interest .....................................................................................................................................  B6	 00 00	
 B7 Dividends .................................................................................................................................  B7	 00 00	
 B8  Arizona income tax refunds .....................................................................................................  B8	 00 00	
 B9  Business income or (loss) from federal Schedule C ................................................................  B9	 00 00	
 
B10  Gains or (losses) from federal Schedule D ..............................................................................  B10	 00 00	
 
B11  Rents, royalties, partnerships, estates, trusts, small business corporations 	from federal Schedule E	 . B11	 00 00	
 
B12  Other income reported on your federal return .........................................................................  B12	 00 00	
 
B13 Total income:  	Add	 lines B5 through B12	 ....................................................................................  B13	 00 00	
 
B14  Other federal adjustments.  	Attach your own schedule	 ................................................................  B14	 00 00	
 
B15  Federal adjusted gross income.  	Subtract line B14 from line B13 in the FEDERAL column	 .............. B15	 00	
 
B16  Arizona income:  	Subtract line B14 from line B13 in the ARIZONA column.  Enter here and on the front of this form on line 15	 ..........  B16	 00	
 
B17 Arizona percentage:  	Divide	 line B16 by line B15, and enter the result (not over 100%)	 ............................................................ B17	 %	
PART C:  Additions to Income
 
C18  I.R.C. §179 expense in excess of allowable amount.  	Also see the instructions for line D30	 ...................................................  C18	 00	
 
C19  Total depreciation included in Arizona gross income .........................................................................................................  C19	 00	
 
C20  Other additions to income.  	See instructions and attach your own schedule	 ..............................................................................  C20	 00	
 
C21 Total:  Add lines C18 through C20.  	Enter here and on the front of this form on line 16	 ............................................................ C21	 00	
PART D:  Subtractions From Income
 
D22  Exemption:  Age 65 or over.  	Multiply the number in box 8, page 1, by $2,100	 ........................................ D22	 00	
 
D23  Exemption:  Blind.  	Multiply the number in box 9, page 1, by $1,500	 ........................................................  D23	 00	
 
D24  Exemption:  Dependents.  	Multiply the number in box 10, page 1, by $2,300	 ..........................................  D24	 00	
 
D25  Total exemptions:  	Add	 lines D22 through D24	 ......................................................................................  D25	 00	
 
D26 Multiply line D25 by the percentage on line B17, and enter the result ...............................................................................  D26	 00	
 
D27  Interest on U.S. obligations such as U.S. savings bonds and treasury bills included in the ARIZONA column .................  D27	 00	
 
D28  Arizona state lottery winnings included on line B12 in the ARIZONA column (up to $5,000 only) .....................................  D28	 00	
 
D29  Agricultural crops contributed to Arizona charitable organizations ....................................................................................  D29	 00	
 
D30  Adjustment for I.R.C. §179 expense not allowed ...............................................................................................................  D30	 00	
 
D31  Other subtractions from income.  	See instructions and attach your own schedule	 ....................................................................  D31	 00	
 
D32 Total:  Add lines D26 through D31.  	Enter here and on the front of this form on line 17	 ............................................................  D32	 00	
Part E:  Last Name(s) Used in Prior Years	 – if different from name(s) used in current year
  E33 	
PLEASE SIGN HERE
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Your Name (as shown on page 1)Your Social Security No.
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. 	
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
       SPOUSE’S SIGNATURE    DATE    SPOUSE’S OCCUPATION
       PAID PREPARER’S SIGNATURE    DATE    FIRM’S NAME (PREPARER’S IF SELF-EMPLOYED)
        (             ) PAID PREPARER’S TIN    PAID PREPARER’S ADDRESS    PAID PREPARER’S PHONE NO.