Indiana Additional Dependent Child Information

Additional Dependent Child Information
Form IN-DEP
Schedule IN-DEP
Form IT-40/IT-40PNR
State Form 54815

Schedule IN-DEP: Dependent Information and Additional
Dependent Child Information

Enclosure
Sequence No. 03A/04A

(R12 / 9-23)
		

Name(s) shown on Form IT-40/IT-40PNR	

Your Social Security Number

	
Dependent’s First Name	
	
	1A.	
	
Dependent’s Social Security Number	

Dependent’s Last Name
1B.

Dependent’s Date of Birth (mm dd yyyy)

	1C.	
1D.
	 1E.	 Place “X” in box 1E if claiming dependent as an additional dependent child exemption__________________ 1E
	 1F.	 Place “X” in box 1F if dependent child claimed for the first time (see instructions)______________________ 1F
	
	
Dependent’s First Name	
Dependent’s Last Name
	
	2A.	
2B.
	
Dependent’s Social Security Number	
Dependent’s Date of Birth (mm dd yyyy)
	
	2C.	
2D.	
	 2E.	 Place “X” in box 2E if claiming dependent as an additional dependent child exemption__________________ 2E
	 2F.	 Place “X” in box 2F if dependent child claimed for the first time (see instructions)______________________ 2F
	
	
Dependent’s First Name	
Dependent’s Last Name
	
	3A.	
3B.
	
Dependent’s Social Security Number	
Dependent’s Date of Birth (mm dd yyyy)
	3C.	
3D.
	 3E.	 Place “X” in box 3E if claiming dependent as an additional dependent child exemption__________________ 3E
	 3F.	 Place “X” in box 3F if dependent child claimed for the first time (see instructions)______________________ 3F
	
	
Dependent’s First Name	
Dependent’s Last Name
	
	4A.	
4B.
	
Dependent’s Social Security Number	
Dependent’s Date of Birth (mm dd yyyy)
	4C.	
4D.
	 4E.	 Place “X” in box 4E if claiming dependent as an additional dependent child exemption__________________ 4E
	 4F.	 Place “X” in box 4F if dependent child claimed for the first time (see instructions)______________________ 4F
	5. Dependent Exemptions. Add the number of dependents listed above (see instructions). Enter the total
here and in the box on line 2 of Schedule 3 (if filing Form IT-40) or Schedule D (if filing Form IT-40PNR)______	 Box 5
	6. Additional Dependent Exemptions. Add the total number of boxes with Xs from lines 1E,1F, 2E, 2F, 3E, 3F,
	
4E and 4F if applicable. Enter the total here and in the box on line 3 of Schedule 3 (if filing Form IT-40)
	
or Schedule D (if filing Form IT-40PNR)_________________________________________________________	 Box 6

*25623111694*
25623111694

2023