Arizona Form FOR CALENDAR YEAR
Credit for Increased Excise Taxes
140ET 2022
82F Check box 82F if filing under extension 95 Check box 95 if amending credit for tax year 2022
Your First Name and Middle Initial Last Name Your Social Security Number
Enter
1 your
Spouse’s First Name and Middle Initial (if box 4 or 6 checked) Last Name Spouse’s Social Security No.
SSN(s).
1
Current Home Address - number and street, rural route Apt. No. Daytime Phone (with area code)
2 94
City, Town or Post Office State ZIP Code REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
3 88
FILING STATUS (check the appropriate box) :
4 Married filing joint claim
5DO NOT STAPLE ANY ITEMS TO THE CLAIM. Head of household: Enter name of qualifying child or dependent on next line:
6 Married filing separate claim: Enter spouse’s name and Social Security Number above. 81 PM 80 RCVD
7 Single
Note: If you are married and you qualify to claim this credit, you must file a married
filing separate claim if your spouse was sentenced for at least 60 days during 2022 to a county, state or federal prison.
8 I have read “Who Can File Form 140ET” on page 2, and I certify that I qualify to claim this credit on this form .. 8 YES NO
Note: If you checked “No”, STOP. DO NOT file Form 140ET.
9 List dependents (see instructions on page 3). If married filing a joint claim, you may list up to 2 dependents;
all others may list up to 3.
SOCIAL SECURITY NUMBER
FIRST NAME LAST NAME OR ITIN
9A1
9A2
9A3
10 Total number of dependents entered on lines 9A1 through 9A3 .................................................................... 10
11 If you checked box 4, enter the number “2” here. If you checked box 5, 6, or 7, enter the number “1” here . 11
12 Add the amount on line 10 and line 11. Enter the total ................................................................................. 12
13 Multiply the amount on line 12 by $25. Enter the result................................................................................ 13 00
Direct Deposit of Refund:
14 Enter the smaller of line Check13 orbox$100...............................................................................................................14A if your deposit will be ultimately placed in a foreign account; see instructions. 14A 14 00
ROUTING NUMBER ACCOUNT NUMBER
C Checking or
98 S Savings
If this is your first claim for 2022, STOP HERE, AND GO TO THE SIGNATURE BOX BELOW.
If this is an amended claim, complete lines 15 through 17, and check box 95 at the top of the form.
AMENDED
15 Enter the amount from line 5 of the worksheet on page 4 of the instructions ............................................... 15 00
16 Additional refund: If line 14 is larger than line 15, subtract line 15 from line 14 ........................................... 16 00
17 Amount to pay: If line 14 is less than line 15, subtract line 14 from line 15 .................................................. 17 00
Make check payable to Arizona Department of Revenue; write your SSN on payment, and include with Form 140ET.
Under penalties of perjury, I declare that I have read this return and any documents with it, and to the best of my knowledge and belief, they are
true, correct and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
YOUR SIGNATURE DATE OCCUPATION
SPOUSE’S SIGNATURE DATE SPOUSE’S OCCUPATION
PAID PREPARER’S SIGNATURE DATE FIRM’S NAME (PAID PREPARER’S, IF SELF-EMPLOYED)
PLEASE SIGN HERE
PAID PREPARER’S STREET ADDRESS PAID PREPARER’S TIN
PAID PREPARER’S CITY STATE ZIP CODE PAID PREPARER’S PHONE NUMBER
ADOR 10532 (22) Mail this claim to: Arizona Department of Revenue, PO Box 52138, Phoenix, AZ 85072-2138.
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