DO NOT STAPLE ANY ITEMS TO THE RETURN.
Arizona Form
140
Check box 82F
if filing under extension
82F
1
OR FISCAL YEAR BEGINNING M M D
Last Name
Spouse’s First Name and Middle Initial (if box 4 or 6 checked)
Apt. No.
State
. 66F
Your Social Security Number
ZIP Code
Spouse’s Social Security No.
Daytime Phone (with area code)
94
2
City, Town or Post Office
MM D D 2 0 Y Y
Enter
your
SSN(s).
Last Name
Current Home Address - number and street, rural route
2015
AND ENDING
1
Last Names Used in Last Four Prior Year(s) (if different)
97
3
4
5


6
7


8
9
10
11
Married filing joint return
Head of household: Enter name of qualifying child or dependent on next line:
Married filing separate return: Enter spouse’s name and Social Security Number above.
Single
Enter the number claimed. Do not put a check mark.
Dependents
(Do not list yourself or spouse.)
10a
10b
10c
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
88
WITH
CREDIT
WITH TAX
TAX CREDIT
DONATION
DONATION
Age 65 or over (you and/or spouse)
If completing lines 8
80 RCVD
81 PM
Blind (you and/or spouse)
through 11, also complete
Dependents: Do not include self or spouse.
lines 38 through 41.
Qualifying parents and grandparents
(Box 10): Dependent Information: Children and other dependents. For more space, (check)  and complete page 3.
(a)
FIRST AND LAST NAME
(b)
(c)
(d)
SOCIAL SECURITY NO. RELATIONSHIP NO. OF MONTHS
LIVED IN YOUR
HOME IN 2015

(e)
if this person
did not qualify as a
dependent on your
federal return



(Box 11): Qualifying parents and grandparents. See instructions. For more space, (check)  and complete page 3.
(a)
FIRST AND LAST NAME
(Do not list yourself or spouse.)
(b)
(c)
(d)
SOCIAL SECURITY NO. RELATIONSHIP NO. OF MONTHS
LIVED IN YOUR
HOME IN 2015
(e)
 if



(f)
 if




12
13
14
15
16
17
85,000
Federal adjusted gross income (from your federal return)....................................................................................
Non-Arizona municipal interest....................................................................................................................................
Partnership Income: See instructions.............................................................................................................................
Total federal depreciation.............................................................................................................................................
Other additions to income: See instructions and include your own schedule.......................................................................
Subtotal: Add lines 12 through 16 and enter the total........................................................................................................
Total net capital gain or (loss): See instructions...................................................................... 18
Total net short-term capital gain or (loss): See instructions..................................................... 19
Total net long-term capital gain or (loss): Enter the amount from your worksheet, line 14, col. (a) 20
Net long-term capital gain from assets acquired after December 31, 2011. Enter the
amount from your worksheet, line 14, col. (c)................................................................................ 21
Multiply line 21 by 25% (.25) and enter the result........................................................................................................
Net capital gain derived from investment in qualified small business..........................................................................
Recalculated Arizona depreciation...............................................................................................................................
Partnership Income: See instructions............................................................................................................................
Adjustment for I.R.C. §179 expense not allowed.........................................................................................................
Interest on U.S. obligations such as U.S. savings bonds and treasury bills.................................................................
Exclusion for federal, Arizona state or local government pensions (up to $2,500 per taxpayer)..................................
00
22
23
24
25
26
27
28
Arizona state lottery winnings included as income on your federal return (up to $5,000 only)....................................
U.S. Social Security or Railroad Retirement Act benefits included as income on your federal return (taxable amount)
Certain wages of American Indians..............................................................................................................................
Pay received for active service as a member of the reserves, national guard or the U.S. armed forces.....................
Net operating loss adjustment: See instructions before you make an entry here.................................................................
Contributions to 529 College Savings Plans................................................................................................................
Other Subtractions: See instructions and include your own schedule..................................................................................
Subtract lines 22 through 35 from line 17. Enter the total...........................................................................................
ADOR 10413 (15)
AZ Form 140 (2015)
29
30
31
32
33
34
35
36
Additions
this person on your
federal return due to
educational credits
died in 2015
12
13
14
15
16
17
18
19
20
21
29
30
31
32
33
34
35
36
(f)
 if you did not claim
age 65 or over
11a
11b
Subtractions
Place any required federal and AZ schedules or other documents after Form 140.
D 2 0 1 5
AZ4EDUCATION
EXEMPTIONS FILING STATUS
Your First Name and Middle Initial
FOR CALENDAR YEAR
Resident Personal Income Tax Return
85,000
00
00
00
22
23
24
25
26
27
28
85,000
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
Page 1 of 3
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
Enter the amount from page 1, line 36............................................................................................................................
Age 65 or over: Multiply the number in box 8 by $2,100........................................................................................................
Blind: Multiply the number in box 9 by $1,500.......................................................................................................................
Dependents: Multiply the number in box 10 by $2,300..........................................................................................................
Qualifying parents and grandparents: Multiply box 11 by $10,000......................................................................................
Arizona adjusted gross income: Subtract lines 38 through 41 from line 37.......................................................................
X
Deductions: Check box and enter amount. See instructions......................... 43I ITEMIZED 43S
STANDARD
Personal exemptions: See instructions.............................................................................................................................
Arizona taxable income: Subtract lines 43 and 44 from line 42.............................................................................................
Compute the tax using amount on line 45 and Tax Table X, Y or Optional Tax Tables....................................................
Tax from recapture of credits from Arizona Form 301, Part 2, line 40.............................................................................
Subtotal of tax: Add lines 46 and 47 and enter the total........................................................................................................
Family income tax credit (from the worksheet - see instructions)...........................................................................................
Credits from Arizona Form 301, Part 2, line 76...............................................................................................................
Balance of tax: Subtract lines 49 and 50 from line 48. If the sum of lines 49 and 50 is more than line 48, enter zero...................
Arizona income tax withheld during 2015........................................................................................................................
Arizona estimated tax payments for 2015.......................................................................................................................
2015 Arizona extension payment (Form 204).................................................................................................................
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
Increased Excise Tax Credit (from the worksheet - see instructions).....................................................................................
Property Tax Credit from Form 140PTC..........................................................................................................................
Other refundable credits: Check the box(es) and enter the total amount........................ 571308-I 572342 573349
Total payments and refundable credits: Add lines 52 through 57 and enter the total........................................................
TAX DUE: If line 51 is larger than line 58, subtract line 58 from line 51 and enter amount of tax due. Skip lines 60, 61 and 62.........
OVERPAYMENT: If line 58 is larger than line 51, subtract line 51 from line 58 and enter amount of overpayment.........................
Amount of line 60 to be applied to 2016 estimated tax...................................................................................................
Balance of overpayment: Subtract line 61 from line 60 and enter the difference.....................................................................
55
56
57
58
59
60
61
62
63 - 72 Voluntary Gifts to:
Refund or
Amount Owed
Tax Due or
Overpayment
Total Payments and
Refundable Credits
Balance of Tax
Exemptions
Voluntary Gifts
Your Social Security Number
Penalty
Your Name (as shown on page 1)
Child Abuse Prevention............ 65
Neighbors Helping Neighbors.. 68
I Didn’t Pay Enough Fund........ 71
00
00
00
Solutions Teams
Assigned to Schools............ 63
00
00
00
00
Domestic Violence Shelter.. 66
Special Olympics................. 69
Sustainable State Parks
and Road Fund.................... 72
00
00
00
Arizona Wildlife................ 64
Political Gift..................... 67
Veterans’ Donations Fund.70
Political Party (if amount is entered on line 67 - check only one): 731Americans Elect 732AZ Green Party 733Democratic 734Libertarian
Estimated payment penalty and Arizona Long-Term Health Care Savings Account (AZLTHSA) penalty....................... 74
751Annualized/Other 752Farmer or Fisherman 753Form 221 included 754AZLTHSA Penalty
Add lines 63 through 72 and 74; enter the total.............................................................................................................. 76
REFUND: Subtract line 76 from line 62. If less than zero, enter amount owed on line 78........................................................... 77
Direct Deposit of Refund: Check box 77A if your deposit will be ultimately placed in a foreign account; see instructions. 77A
ROUTING NUMBER
ACCOUNT NUMBER
CChecking or
98
SSavings
78 AMOUNT OWED: Add lines 59 and 76. Make check payable to Arizona Department of Revenue; write your SSN on payment,
and include with your return.................................................................................................................................................. 78
73
74
75
76
77
85,000
85,000
9,000
3,000
73,000
2,150
2,150
2,134
16
2,500
2,500
2,484
735
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
Republican
00
2,484
00
00
00
PLEASE SIGN HERE
Under penalties of perjury, I declare that I have read this return and any documents with it, and 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
SPOUSE’S SIGNATURE
PAID PREPARER’S SIGNATURE
DATE
DATE
DATE
OCCUPATION
SPOUSE’S OCCUPATION
FIRM’S NAME (PREPARER’S IF SELF-EMPLOYED)
PAID PREPARER’S STREET ADDRESS
PAID PREPARER’S CITY
STATE
ZIP CODE
PAID PREPARER’S TIN
(
)
PAID PREPARER’S PHONE NUMBER
If you are sending a payment with this return, mail to Arizona Department of Revenue, PO Box 52016, Phoenix, AZ, 85072-2016.
Include the payment with Form 140.
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 10413 (15)
AZ Form 140 (2015)
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