Form
1040X
(Rev. January 2017)
Department of the Treasury—Internal Revenue Service
Amended U.S. Individual Income Tax Return
▶
Information about Form 1040X and its separate instructions is at www.irs.gov/form1040x.
OMB No. 1545-0074
This return is for calendar year
2016 2015 2014 2013
Other year. Enter one: calendar year or fiscal year (month and year ended):
Your first name and initial Last name
Your social security number
If a joint return, 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 instructions).
Foreign country name Foreign province/state/county Foreign postal code
Amended return filing status. You must check one box even if you are not changing
your filing status. Caution: In general, you can’t change your filing status from joint to
separate returns after the due date.
Single
Married filing jointly
Married filing separately
Qualifying widow(er)
Head of household (If the qualifying person is a child but not
your dependent, see instructions.)
Full-year coverage.
If all members of your household have full-
year minimal essential health care coverage,
check "Yes." Otherwise, check "No."
(See instructions.)
Yes No
Use Part III on the back to explain any changes
A. Original amount
or as previously
adjusted
(see instructions)
B. Net change—
amount of increase
or (decrease)—
explain in Part III
C. Correct
amount
Income and Deductions
Tax Liability
Payments
1 Adjusted gross income. If net operating loss (NOL) carryback is
included, check here . . . . . . . . . . . . . . .
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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 . . . . . . . . . . 5
Tax. Enter method(s) used to figure tax (see instructions):
6
7 Credits. If general business credit carryback is included, check
here . . . . . . . . . . . . . . . . . . . . .
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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
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 year’s
return . . . . . . . . . . . . . . . . . . . . . .
13
14 Earned income credit (EIC) . . . . . . . . . . . . . . . 14
15
Refundable credits from:
Schedule
8812
Form(s)
2439
4136 8863 8885 8962 or
other (specify):
15
16
Total amount paid with request for extension of time to file, tax paid with original return, 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
estimated tax .
(enter year): 23
Complete and sign this form on Page 2.
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 11360L
Form
1040X (Rev. 1-2017)
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