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it 140 Form 2016
Name
MI
First Line of Address
Second Line of Address
—
City
State
Zip Code
Telephone Number: __________________________________________
Amended
return
Check before 4/18/17 if you wish to stop the
original debit (amended return only)
Net Operating
Loss
Nonresident/ Part-Year
Resident
(See instructions on Page 15)
Nonresident Special
Exemptions: (If someone can claim you as a dependent, leave
box (a) blank.)
Filing Status
(Check One)
Enter “1” in boxes a
and b if they apply
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