Form 1040-X

This return is for calendar year (enter year)

or fiscal year (enter month and year ended)

Your Name

First NameLast Name

Your social security number

Spouse's Name

First NameLast Name

Spouse's social security number

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Presidential Election Campaign: Check here if you, or your spouse if filing jointly, want $3 to go to this fund.

Amended return filing status. You must check one box even if you are not changing your filing status.

If you checked the MFS box, enter the name of your spouse unless you are amending a Form 1040-NR. If you checked the HOH or QSS box, enter the child's name if the qualifying person is a child but not your dependent:

First NameLast Name

Income and Deductions 1 Checkbox

Part I Dependents

Rows	A. Original number of dependents reported or as previously adjusted	B. Net change- amount of increase or (decrease)	C. Correct number
1
2
3
4a
4b
5
6
7
8
9
10
11
12
13
14
15

6 Tax. Enter method(s) used to figure tax. See instructions:

15 Refundable credits from:

16 Total amount paid with request for extension of time to file...

17 Total payments. Add lines 12 through 15, column C, and line 16

18 Overpayment, if any, as shown on original return...

19 Subtract line 18 from line 17.

20 Amount you owe. If line 11, column C, is more than line 19, enter the difference.

21 If line 11, column C, is less than line 19, enter the difference. This is the amount overpaid on this return

22 Amount of line 21 you want refunded to you

23 Amount of line 21 you want applied to your (enter year): estimated tax

Rows	A. Original number of dependents reported or as previously adjusted	B. Net change- amount of increase or (decrease)	C. Correct number
24
25
26
27
28
29

Rows	Dependent 1	Dependent 2	Dependent 3	Dependent 4	Dependent 4	Dependent 4
(1) First name
(2) Last name
(3) SSN
(4) Relationship
(5) Check if lived with you more than half of return year entered at top of page 1
(5) Check if lived with you more than half of return year entered at top of page 1

1040-X

Part I Dependents

Part II Explanation of Changes

Sign Here

Paid Preparer Use Only