Department of the Treasury—Internal Revenue Service

Department of the Treasury—Internal Revenue Service 11040X (Rev. January 2018) ► Go to wwwirs.gov/Fonn1040X for instructions and the latest information. This return is for calendar year 0 2017 0 2016 0 2015 0 2014 Other year. Enter one: calendar year or fiscal year (month and year ended): Your first name and initial Amended U.S. Individual Income Tax Return OMB No. 154S-0074 Last name Your social security number If a joint retum. spouse's first name and initial last name Spouse's social security number Current home address (number and street). If you have a P.O. box. see instructions. Apt. no. Your phone number City, town or post office. state, and ZIP code. If you have a foreign address. also complete spaces below (see nstrucbons). Foreign country name Foreign province/state/county Foreign postal code Amended return filing status. your filing status. Caution: return to separate returns after 0 Single 0 Married filing jointly 0 Married filing separately In . 0 You must check one box even if you are not changing general, you can't change your fi ing status from a joint the due date. Head of household (If the qualifying person Is a child but not your dependent, see instructions.) Qualifying widow(er) Full-year coverage. If all members of your household have full- year minimal essential health care coverage, check "Yes." Otherwise, check "No." See instructions. 0 Yes 0 No Use Part Ill on the back to explain any changes Original amount A. ce as previously adjusted B. Net change— amount of increase or (decrease)— C. Correct amount Income and Deductions (see instructions) explain in Part III 1 Adjusted gross income. If a net operating loss (NOL) canyback is included, check here le D 1 2 Itemized deductions or standard deduction 2 3 Subtract line 2 from line 1 3 4 Exemptions. If changing, complete Part I on page 2 and enter the amount from line 29 4 5 Taxable income. Subtract line 4 from line 3 Tax Liability 6 Tax. Enter method(s) used to figure tax (see instructions): 6 7 Credits. If a general business credit carryback is included, check here lo CI 7 8 Subtract line 7 from line 6. If the result is zero or less, enter -0- . 8 9 Health care: individual responsibility (see instructions) 9 10 Other taxes 10 11 Total tax. Add lines 8, 9, and 10 11 Payments 12 Federal income tax withheld and excess social security and tier 1 RRTA tax withheld. (If changing, see instructions.) 12 13 Estimated tax payments, including amount applied from prior years return 13 14 Earned income credit (EIC) 14 15 Refundable credits from: OSchedule 8812 Form(s) O 2439 04136 Oases • 8885 08962 or Dottier (specify): 15 16 Total amount paid with request for extension of time to file, tax paid with original retum, and additional tax paid after return was filed 16 17 Total payments. Add lines 12 through 15, column C, and line 16 17 Refund or Amount You Owe 18 Overpayment, if any, as shown on original return or as previously adjusted by the IRS 18 19 Subtract line 18 from line 17 (If less than zero, see instructions . ) 19 20 Amount you owe. If line 11, column C, is more than line 19, enter the difference 20 21 If line 11, column C, is less than line 19, enter the difference. This is the amount overpaid on this return 21 22 Amount of line 21 you want refunded to you 22 23 Amount of line 21 you want applied to your (enter year): estimated tax . 1231 Complete and sign this onn on Page 2. For Paperwork Reduction Act Notice, see Instructions. Form 1040X (Rev. 1-2018) EFTA01222573 Form 1040X (Rev. 1-2018) Page 2 hiall_Exemptions Complete this part only if any information relating to exemptions has changed from what you reported on the return you are amending. This would include a change in the number of exemptions, either personal exemptions or dependents. See Form 1040 or Form 1040A instructions and Form 1040X instructions. A. Original number of exemptions or amount mooned or as previously adjusted S. Net change C. Correct number or amount 24 Yourself and spouse. Caution: If someone can claim you as a dependent, you can't claim an exemption for yourself 24 25 Your dependent children who lived with you 25 26 Your dependent children who didn't live with you due to divorce or separation 26 27 Other dependents 27 28 Total number of exemptions. Add lines 24 through 27 28 29 Multiply the number of exemptions claimed on line 28 by the exemption amount shown in the instructions for line 29 for the year you are amending. Enter the result here and on line 4 on page 1 of this form. . 29 30 List ALL dependents (children and others) claimed on this amended return. If more than 4 dependents, see instructions. (a) First name Last name (b) Dependent's social security number lo) Dependent's relationship to you (d) box H ng chNd for Check child tax qualifyi credit (see Instructions) 0 0 0 0 Part Presidential Election Campaign Fund Checking below won't increase your tax or reduce your refund. K Check here if you didn't previously want $3 to go to the fund, but now do. K Check here if this is a joint return and your spouse did not previously want $3 to go to the fund, but now does. Part III Explanation of changes. In the space provided below, tell us why you are filing Form 1040X. O. Attach any supporting documents and new or changed forms and schedules. Remember to keep a copy of this form for your records. Under penalties of perjury. I declare that I have filed an original return and that I have examined this amended return. including accompanying schedules and statements, and to the best of my knowledge and belief. this amended return is true. conect. and complete. Declaration of preparer (other than taxpayer) is based on all information about which the preparer has any knowledge. Sign Here Your signature Date Your occupation Spouse's signature. If a joint return, both must sign. Date Spouse's occupation Paid Preparer Use Only Preparer's signature Date Arm's name (or yours if self-employed) Print/type preparer's name Arm's address and ZIP code 0 Check if self-employed PTIN Phone number EIN For forms and publications, visit IRS.gov. Form 1040X (Rev. 1-2018) EFTA01222574