R-540X (1/13)

                            2012 Louisiana Resident Amended                                   TAXPAYER COPY
                              Return Information Sheet
                                                                                               DO NOT MAIL.

Your first name and initial                      Last name                                     Your Social Security Number

If joint return, spouse’s first name and initial Last name                                     Spouse’s Social Security Number

Present home address

City, Town or APO                                                           State              ZIP

Filing Status 
On original return: ■ Single    ■ Married filing jointly   ■ Married filing separately        ■ Head of household ■ Qualifying widow(er)
On this return:     ■ Single    ■ Married filing jointly   ■ Married filing separately        ■ Head of household ■ Qualifying widow(er)

                                                                                               A                  B               C
                                                                                              Original amount  Net change —       Correct amount
                                                                                              or as previously amount of increase 
                                                                                               adjusted        or (decrease)
Number of Exemptions
Yourself and Spouse (includes 65 or older, Blind, and Qualifying Widow(er)) Total of 6A and 6B

6C  Number of Dependents                                                               6C

6D  Total Exemptions                                                                   6D
Louisiana Tax Table Income and Tax
7   Federal Adjusted Gross Income                                                      7

8A  Federal Itemized Deductions                                                        8A

8B  Federal Standard Deduction                                                         8B

8C  Excess Federal Itemized Deductions                                                 8C

9   Federal Income Tax (Mark box if federal income tax has been decreased.)       ■    9

10  Your Louisiana Tax Table Income                                                    10

11  Your Louisiana Income Tax                                                          11
Nonrefundable Tax Credits
12A Federal Child Care Credit                                                       12A

12B 2012 Louisiana Nonrefundable Child Care Credit                                  12B

12C Amount of Louisiana Nonrefundable Child Care Credit Carried Forward from        12C
    Previous Years
12D 2012 Louisiana Nonrefundable School Readiness Credit                            12D

12E Amount of Louisiana Nonrefundable School Readiness Credit Carried Forward       12E
    from Previous Year
13  Education Credit                                                                   13

14  Other Nonrefundable Tax Credits                                                    14

15  Total Nonrefundable Tax Credits                                                    15

R-540X (1/13)

                     2012 Louisiana Resident Amended                                    TAXPAYER COPY
                          Return Information Sheet
                                                                                        DO NOT MAIL.
                                                                                        A                B                  C
                                                                                        Original amount  Net change —       Correct amount
                                                                                        or as previously amount of increase 
                                                                                        adjusted         or (decrease)
Total Income Tax and Consumer Use Tax
16  Adjusted Louisiana Income Tax                                                    16

17  Consumer Use Tax                                                                 17

18  Total Income Tax and Consumer Use Tax                                            18
Refundable Tax Credits and Payments
19  2012 Louisiana Refundable Child Care Credit                                      19

19A Qualified Expense from the Refundable Child Care Credit Worksheet                19A

19B Amount from the Refundable Child Care Credit Worksheet                           19B

20  2012 Louisiana Refundable School Readiness Credit                                20

21  Earned Income Credit                                                             21

22  Louisiana Citizens Insurance Credit                                              22

23  Other Refundable Tax Credits                                                     23

24  Amount of Louisiana Tax Withheld for 2012                                        24

25  Amount of Credit Carried Forward from 2011                                       25

26  Amount Paid on Your Behalf by a Composite Partnership Filing                     26

27  Amount of Estimated Payments Made for 2012                                       27

28  Amount Paid with Extension Request                                               28

29  Total Refundable Tax Credits and Payments                                        29
Overpayment
30  Overpayment                                                                      30

31  Underpayment Penalty (Mark box if you are a farmer with underpayment penalty.) ■ 31

32  Adjusted Overpayment                                                             32
Donations
33  Total Donations                                                                  33
Refund Due
34  Subtotal                                                                         34

35  Amount to be Credited to 2013 Income Tax                          CREDIT         35

36  Amount to be Refunded                                             REFUND         36

R-540X (1/13)

                  2012 Louisiana Resident Amended                                     TAXPAYER COPY
                             Return Information Sheet
                                                                                      DO NOT MAIL.
                                                                                      A                B                  C
                                                                                      Original amount  Net change —       Correct amount
                                                                                      or as previously amount of increase 
                                                                                      adjusted         or (decrease)
Amounts Due Louisiana
37 Amount You Owe                                                                   37

38 Additional Donation to the Military Family Assistance Fund                       38

39 Additional Donation to the Coastal Protection and Restoration Fund               39

40 Additional Donation to Louisiana Chapter of the National Multiple Sclerosis      40
   Society Fund
41 Additional Donation to Louisiana Food Bank Association                           41

42 Interest                                                                         42

43 Delinquent Filing Penalty                                                        43

44 Delinquent Payment Penalty                                                       44

45 Underpayment Penalty (Mark box if you are a farmer with underpayment penalty.) ■ 45

46 Balance Due Louisiana                                                            46