Fill and Sign the Medical Report Form 14211880

Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes. Illinois Department of Revenue 2008 Form IL-1040-X Amended Individual Income Tax Return / or for fiscal year ending 0 9 REV 11 Step 1: Personal information A Do not write above this line. Print or type your current Social Security number(s), name(s), and address. – Your Social Security number Your first name and initial – – Spouse’s Social Security number Spouse’s first name (and last name - only if different) Mailing address B C D E – Your last name City State ZIP If your Social Security number(s), name(s), or address listed above are different from your previously filed return, check the box. Filing Status: Residency: Single or head of household Resident Married filing jointly Nonresident Married filing separately Widowed Part-year resident Check the box that identifies why you are making this change. ** Attach a copy of your federal finalization. (See instructions.) **Federal change accepted on ____ ___ ____ Month Day **NOL accepted on Year ____ ____ ____ Month Day State change Year Step 2: Reason for filing If you are changing your Illinois return due to a change to your federal return, do not file this form until you receive notification that the IRS has accepted the changes. See ‘‘How long do I have to correct or amend my return?’’ in the Form IL-1040-X instructions. Staple W-2 and 1099 forms here. F For the tax year you are amending, on what date did you file your original Form IL-1040 or your latest Form IL-1040-X? G Did you file a U.S. Form 1040X? yes no If you filed a U.S. Form 1040X, you must attach to this form a copy of your U.S. Form 1040X, and a copy of the notification you received from the Internal Revenue Service (IRS) stating that they accepted the changes shown on your U.S. Form 1040X; e.g., a refund check, "Statement of Account," agreement, or judgment. You must write the date the IRS notified you (not the date you filed your U.S. 1040X) in the appropriate space in Step 1, Line E. Failure to provide this date could result in an assessment of a late-payment penalty. H Explain, in detail, the reason(s) for filing this amended return. Attach a separate sheet if necessary. Total Tax Net Income Exemptions Subtractions Income Step 3: Financial information (Line numbers may not match your original return.) Staple your check here. ______/______/______ 1 2 3 4 5 6 7 8 9 10 Corrected Figures Federal adjusted gross income Federally tax-exempt interest and dividend income Other additions (attach Schedule M with amended figures) Total income. Add Lines 1 through 3. Federally taxed Social Security and federally taxed retirement plan income Illinois Income Tax overpayment included in U.S. 1040, Line 10 (attach U.S. 1040, page 1) Other subtractions (attach Schedule M with amended figures) Total subtractions – Add Lines 5 through 7. Illinois base income. Subtract Line 8 from Line 4. Number of exemptions: a yourself and your dependents (as corrected) b 65 years or older or legally blind (as corrected) c Add Lines 10a and 10b. This is your exemption allowance. X $2000 X $1000 11 Residents only: Net income. Subtract Line 10c from Line 9. 12 Nonresidents and part-year residents only: Write your Illinois base income from Schedule NR. (attach Schedule NR with amended figures) 12 1 2 3 4 5 6 7 8 9 10a 10b 10c 11 _____________|____ _____________|____ _____________|____ _____________|____ _____________|____ _____________|____ _____________|____ _____________|____ _____________|____ _____________|____ _____________|____ _____________|____ _____________|____ _____________|____ 13 Residents: Multiply Line 11 by 3% (.03). Nonresidents and part-year residents: Write the tax before recapture of investment credits from Schedule NR. 13 _____________|____ 14 _____________|____ 15 _____________|____ 14 Recapture of investment tax credits. Attach Schedule 4255. 15 Total Tax. Add Lines 13 and 14. IL-1040-X (R-12/08) *861501110* Official Use Page 1 of 4 Previous Overpayments Payments and Refundable Credit Corrected Figures 16 Total tax amount from Page 1, Line 15. Nonrefundable Credits Step 3 (Continued) 16 _____________|____ 17 Credit from Schedule CR (attach Schedule CR with amended figures) 18 Property tax and K-12 education expense credit from Schedule ICR (attach Schedule ICR 17 _____________|____ with amended figures) 19 Credit from Schedule 1299-C (attach Schedule 1299-C with amended figures) 20 Nonrefundable credits. Add Lines 17 through 19. 21 Tax after nonrefundable credits. Subtract Line 20 from Line 16. 18 19 20 21 _____________|____ _____________|____ _____________|____ _____________|____ 22 Total of all previous overpayments, refunds, or credit carryforward (whether or not you 22 _____________|____ 23 _____________|____ received it), and original contributions. (See instructions) 23 Tax after previous overpayments. Add Line 21 and 22. 24 25 26 27 28 29 24 Estimated payments (IL-1040-ES, IL-505-I, and prior year credit) 25 Pass-through entity payments - nonresident and part-year residents only (attach Schedule K-1-P or K-1-T) 26 Earned income credit from Schedule ICR (attach Schedule ICR with amended figures) 27 Amount of tax paid with original return plus additional tax paid after it was filed. (See instructions) 28 Total payments and refundable credit. Add Lines 24 though 28. 29 Illinois Income Tax withheld (See instructions.) _____________|____ _____________|____ _____________|____ _____________|____ _____________|____ _____________|____ Refund or Balance Due Step 4: Refund or Balance Due 30 Overpayment. If Line 23 is less than Line 29, subtract Line 23 from Line 29. 31 Underpayment. If Line 23 is greater than Line 29, subtract Line 29 from Line 23. 32 Penalty and interest. (See instructions) _____________|____ + _____________|____ = Penalty amount 30 _____________|____ 31 _____________|____ 32 _____________|____ Interest amount 33 If Line 30 is greater than Line 32, subtract Line 32 from Line 30. This is your refund. 34 If Line 30 is less than Line 32, subtract Line 30 from Line 32. or If you have an amount on Line 31, add Lines 31 and 32. This is the amount you owe. 33 _____________|____ 34 _____________|____ Step 5: Sign and Date Sign and Date Under penalties of perjury, I state that I have examined this return, and, to the best of my knowledge, it is true, correct, and complete. Your signature Date Daytime phone number Your spouse’s signature Date Paid preparer’s signature Date Preparer’s phone number Preparer’s FEIN, SSN, or PTIN Mail to: Illinois Department of Revenue, P.O. Box 19007, Springfield, IL 62794-9007 *861502110* DR Page 2 of 4 ID X3 This form is authorized as outlined by the Illinois Income Tax Act. Disclosure of this information is REQUIRED. Failure to provide information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-0074 Reset Print IL-1040-X (R-12/08) Supporting Documents for Form IL-1040-X Do not mail this page with your Form IL-1040-X. Federal Changes (including net operating loss (NOL) deductions) If you file Form IL-1040-X because of a change to your federal return or because you are claiming an NOL carryback deduction, you must wait to file this form until you receive a federal finalization notice from the Internal Revenue Service (IRS) stating that they have accepted your change either by paying a refund or by final assessment, agreement, or judgment. You must write the date the IRS notified you (not the date you filed your U.S. Form 1040X) in the appropriate space in Step 1, Line E. Failure to provide this date could result in an assessment of a late-payment penalty. attach proof of federal finalization to your Form IL-1040-X. Acceptable proof of federal finalization includes a copy of the notification you received from the IRS that they accepted your changes; e.g., a refund check, "Statement of Account," agreement, or judgment, and a copy of your U.S. Form 1040X, if filed, or a complete copy of your U.S. Form 1045, Application for Tentative Refund, including all pages of Schedules A and B, along with a copy of your refund check, if you filed your federal amended return due to a NOL. If you do not have a copy of this notification, please contact the IRS at 1 800 829-0922 to request a record of your account. Line Changes Attach the proper supporting documents, listed below, to your return. If you changed any of the lines identified below and do not attach the required supporting documents to your return, we may partially or totally deny your claim. If you corrected: Line 1 Federal adjusted gross income U.S. Form 1040, 1040X, or 1045 (with Schedules A and B, if completed) if a NOL, U.S. Form 1040 Schedules C, E, and F, if filed, for loss years Schedule K-1-P or K-1-T, or any other notification that was furnished to you for partnership, S corporation, estate, and trust income Proof of federal finalization as listed above Line 3 Other additions Schedule M with amended figures and any other required support listed on Schedule M Line 5 U.S. Form 1040 or 1040A, Page 1 Federally taxed Social Security and federally taxed retirement plan income Form W-2, if applicable Line 6 U.S. Form 1040, Page 1 Form 1099-R, RRB-1099, or SSA-1099, if applicable Illinois Income Tax overpayment included in U.S. 1040, Line 10 Continued on the next page IL-1040-X (R-12/08) Page 3 of 4 Supporting Documents for Form IL-1040-X (Continued) Do not mail this page with your Form IL-1040-X. If you corrected: Line 7 Other subtractions Schedule M with amended figures and any other required support listed on Schedule M Line 10 U. S. Form 1040X Exemption allowance Proof of federal finalization as shown above Line 12 Schedule NR with amended figures Nonresidents and part-year residents Line 17 Schedule CR with amended figures Credit for tax paid to other states Out-of-state returns, schedules, and attachments and W-2 forms to support any local taxes paid Line 18 Schedule ICR with amended figures and any other required support listed on Schedule ICR Property tax and K-12 education expense credit from Schedule ICR Line 19 Receipts for home school expenses Schedule 1299-C with amended figures Schedule 1299-C Credits Line 24 Illinois Income Tax withheld All W-2 and 1099 forms, Form IL-4852, or letter, on company letterhead, from employer IL-1023-C Line 26 Schedule K-1-P or K-1-T with amended figures Pass-through entity payments Line 27 Earned Income Credit Page 4 of 4 U.S. Form 1040X, if changing federal EIC Proof of federal finalization IL-1040-X (R-12/08)