88 REVENUE USE ONLY. DO NOT MARK IN THIS AREA. 81 PM 80 RCVD DO NOT STAPLE ANY ITEMS TO THE CLAIM. ADOR 10567 (21) You must file this form or Arizona Form 204 by April 15, 2022. QUALIFICATIONS FOR CREDIT (Check the boxes that apply): 4 On December 31, 2021, were you renting or did you own? If you own a mobile home but rent the space, check “Rent”.................................................... 4 Rent Own   5 Were you an Arizona resident for all of 2021? If “No”, STOP. You do not qualify........................................................................ 5 Yes No   6 Did you pay property taxes on your home, pay rent, or pay a combination of both in 2021? See instructions for qualifications. If “No”, STOP. You do not qualify........................................................................ 6   7 Is this the only Property Tax Refund being claimed in your household? If “No”, STOP. You do not qualify........................................................................ 7   8 Were you age 65 or older in 2021? Enter your birth date in box 79 above......... 8   9 Did you receive Title 16, SSI payments in 2021? If “Yes”, include proof. If you answered “No” to both 8 and 9, STOP. You do not qualify......................... 9   INCOME 10 Total Household Income: Enter the amount from page 2, Part 1, line J, column 4......................................................... 10 00 CREDIT 11 a If you lived alone, enter the amount of credit from page 2, Part 1, Schedule 1, and check the box..............................................................................................................................11a  Schedule 1

b If you lived with your spouse or one or more other persons, enter the amount of credit from page 2, Part 1, Schedule 2, and check the box.........................................................11b  Schedule 2 11 00 12 If you owned your property, enter property taxes actually paid during 2021. Include proof of property taxes paid during 2021................................................................................................................................... 12 00 13 If you rented, enter property taxes paid by your landlord on your portion of rents. Include Form 201........................... 13 00 14 Total property taxes paid in 2021. Add lines 12 and 13.................................................................................................. 14 00 15 Amount of Property Tax Credit: Enter the smaller of line 11 or line 14....................................................................... 15 00 16 If you have been claimed as a dependent on anyone else’s tax return, complete the following: Name Of Taxpayer Who Claimed You Social Security Number Address:

If you are not claimed as a dependent on anyone else’s tax return, turn the form over and complete Part 2. If someone else claims you as a dependent, skip lines 17 and 18, and complete line 19. 17 Credit for increased excise taxes from Form 140PTC, page 2, Part 2, line 6............................................................... 17 00 18 Enter the number from page 2, Part 2, line 2, here....................................................................................... 18 19 Total Credit: Add lines 15 and 17, and enter the total. See the instructions if you have to file

Arizona Form 140 or Form 140A..................................................................................................................................... 19 00 If this is your first claim for 2021, STOP HERE AND GO TO THE SIGNATURE BOX ON PAGE 2. If this is an amended claim, complete lines 20 through 22, and check box 95 at the top of the form. AMENDED 20 Enter the amount from line 5 of the worksheet on page 6 of the instructions.................................................................. 20 00 21 Additional refund: If line 19 is larger than line 20, subtract line 20 from line 19.............................................................. 21 00 22 Amount to pay: If line 19 is less than line 20, subtract line 19 from line 20. Make check payable to Arizona Department of Revenue; write your SSN on payment, and include your payment with Form 140PTC............. 22 00 Continued on page 2  3 95 Check box 95 if amending claim for tax year 2021 1 1 2 82F Check box 82F if filing under extension 79 Your First Name and Middle Initial Last Name Your Social Security Number Spouse’s First Name and Middle Initial (if a joint claim) Last Name Spouse’s Social Security No. Current Home Address - number and street, rural route Apt. No. Daytime Phone (with area code) City, Town or Post Office State ZIP Code Your Date of Birth M M D D Y Y Y Y Enter your SSN(s). 94 Arizona Form 140PTC Property Tax Refund (Credit) Claim FOR CALENDAR YEAR 2021 98 C  Checking or S  Savings Direct Deposit of Refund: Check box 19A if your deposit will be ultimately placed in a foreign account; see instructions. 19A

ROUTING NUMBER ACCOUNT NUMBER

ADOR 10567 (21)

AZ Form 140PTC (2021) Page 2 of 2 Part 2 Credit for Increased Excise Taxes Do not complete Part 2 if you completed line 16 on page 1 of Form 140PTC. Do not complete Part 2 if you were sentenced for at least 60 days of 2021 to a county, state, or federal prison. Note: If you are filing a joint Property Tax Credit claim with your spouse, and you are also claiming the Excise Tax Credit on Form 140PTC, you cannot claim the Excise Tax Credit for your spouse if your spouse was sentenced for at least 60 days during 2021 to a county, state or federal prison. 1 List dependents. See the instructions. (a) FIRST AND LAST NAME (Do not list yourself or spouse.) (b) SOCIAL SECURITY NO. (c) RELATIONSHIP (d) NO. OF MONTHS LIVED IN YOUR HOME IN 2021 1a 1b 1c 2 Enter total number of dependents listed on lines 1a through 1c. Also, enter this amount on Form 140PTC, page 1, line 18...... 2 3 If you are married filing a joint claim, enter the number “2” here. Otherwise, enter the number “1”............................................... 3 4 Add the amount on line 2 and line 3, and enter the total................................................................................................................... 4 5 Multiply the amount on line 4 by $25, and enter the result................................................................................................................ 5 00 6 Enter the smaller of line 5 or $100. Also, enter this amount on Form 140PTC, page 1, line 17..................................................... 6 00 Your Name (as shown on page 1) Your Social Security Number Mail to Arizona Department of Revenue, PO Box 52138, Phoenix, AZ 85072-2138   PLEASE SIGN HERE 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 (PREPARER’S IF SELF-EMPLOYED)

PAID PREPARER’S STREET ADDRESS

PAID PREPARER’S TIN

PAID PREPARER’S CITY STATE ZIP CODE

PAID PREPARER’S PHONE NUMBER 2021 Schedule 1 If you live alone, use this Schedule. 2021 Schedule 2 If you live with your spouse or another person, use this Schedule. Household Income Tax Credit Household Income Tax Credit Household Income Tax Credit Household Income Tax Credit $ 0 - 1,750 $502 $ 2,751 - 2,850 $256 $ 0 - 2,500 $502 $ 4,001 - 4,150 $256 1,751 - 1,850 479 2,851 - 2,950 234 2,501 - 2,650 479 4,151 - 4,300 234 1,851 - 1,950 457 2,951 - 3,050 212 2,651 - 2,800 457 4,301 - 4,450 212 1,951 - 2,050 435 3,051 - 3,150 189 2,801 - 2,950 435 4,451 - 4,600 189 2,051 - 2,150 412 3,151 - 3,250 167 2,951 - 3,100 412 4,601 - 4,750 167 2,151 - 2,250 390 3,251 - 3,350 145 3,101 - 3,250 390 4,751 - 4,900 145 2,251 - 2,350 368 3,351 - 3,450 123 3,251 - 3,400 368 4,901 - 5,050 123 2,351 - 2,450 345 3,451 - 3,550 100 3,401 - 3,550 345 5,051 - 5,200 100 2,451 - 2,550 323 3,551 - 3,650 78 3,551 - 3,700 323 5,201 - 5,350 78 2,551 - 2,650 301 3,651 - 3,750 56 3,701 - 3,850 301 5,351 - 5,500 56 2,651 - 2,750 279 3,751 and up 0 3,851 - 4,000 279 5,501 and up 0 Enter the amount of credit on the front of this form, line 11. Use the amount on line J, column 4, to compute your credit from the proper schedule below. Part 1 Schedule of Household Income (1) YOU (2) YOUR SPOUSE (3) OTHER PERSONS (4) TOTAL (1+2+3) A Salaries, wages, tips, etc., received in 2021............................................ A B Dividend and interest income received in 2021........................................ B C Business and farm income....................................................................... C D Gain or loss from sale or exchange of property........................................ D E Pension and annuity income. Include Arizona state and local retirement benefits, civil service, and military retirement. Do not include social security or railroad retirement benefits......................... E F Rent and royalty income........................................................................... F G S corporation, partnership, estate, and trust income................................ G H Alimony..................................................................................................... H I Other Income: Specify source on separate sheet................................... I J Total household income: Add lines A through I in column (4). Enter here and on the front of this form, line 10............................ J