Form

1040X Department of the TreasuryInternal Revenue Service

Amended U.S. Individual Income Tax Return OMB No. 1545-0074

(Rev. January 2016) Information about Form 1040X and its separate instructions is at www.irs.gov/form1040x.
This return is for calendar year 2015 2014 2013 2012
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, spouses first name and initial Last name Spouses 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 Full-year coverage.
your filing status. Caution: In general, you cannot change your filing status from joint to If all members of your household have full-
separate returns after the due date. year minimal essential health care coverage,
Single Head of household (If the qualifying person is a child but not check "Yes." Otherwise, check "No."
Married filing jointly your dependent, see instructions.) (See instructions.)
Married filing separately Qualifying widow(er) Yes No
A. Original amount B. Net change
Use Part III on the back to explain any changes or as previously amount of increase C. Correct
adjusted or (decrease) amount
Income and Deductions (see instructions) explain in Part III

1 Adjusted gross income. If net operating loss (NOL) carryback is

included, check here . . . . . . . . . . . . . . . 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 Liability
6 Tax. Enter method(s) used to figure tax (see instructions):
6
7 Credits. If general business credit carryback is included, check
here . . . . . . . . . . . . . . . . . . . . . 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: Schedule 8812 Form(s) 2439 4136
8801 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 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 . 23
Complete and sign this form on Page 2.
For Paperwork Reduction Act Notice, see instructions. Cat. No. 11360L Form 1040X (Rev. 1-2016)
Form 1040X (Rev. 1-2016) Page 2
Part I Exemptions
Complete this part only if you are increasing or decreasing the number of exemptions (personal and dependents) claimed on line 6d of
the return you are amending.

A. Original number
of exemptions or C. Correct
See Form 1040 or Form 1040A instructions and Form 1040X instructions. amount reported or B. Net change number
as previously or amount
adjusted
24 Yourself and spouse. Caution: If someone can claim you as a
dependent, you cannot claim an exemption for yourself . . . . . 24
25 Your dependent children who lived with you . . . . . . . . . 25
26 Your dependent children who did not 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.
(d) Check box if qualifying
(b) Dependents social (c) Dependents
(a) First name Last name child for child tax credit (see
security number relationship to you
instructions)

Part II Presidential Election Campaign Fund

Checking below will not increase your tax or reduce your refund.
Check here if you did not previously want $3 to go to the fund, but now do.
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.
Attach any supporting documents and new or changed forms and schedules.

Sign Here
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, correct, and complete. Declaration of preparer
(other than taxpayer) is based on all information about which the preparer has any knowledge.

Your signature Date Spouses signature. If a joint return, both must sign. Date
Paid Preparer Use Only

Preparers signature Date Firms name (or yours if self-employed)

Print/type preparers name Firms address and ZIP code

Check if self-employed
PTIN Phone number EIN

For forms and publications, visit IRS.gov. Form 1040X (Rev. 1-2016)