Indiana IT-40EZ Income Tax Form (OBSOLETE)

IT-40EZ Income Tax Form (OBSOLETE)
IT-40EZ (09-12).indd
IT-40EZ

State Form 48438
(R14 / 9-15)

Your Social
Security Number

2015

□ Check if applying for ITIN

Indiana Income Tax Return for Full-Year
Indiana Resident Filers With No Dependents

Due April 18, 2016

Spouse’s Social
Security Number

□

Your first name	

Initial	

Check if applying for ITIN
Last name	

Suffix

If filing a joint return, spouse’s first name	

Initial	

Last name	

Suffix

Present address (number and street or rural route)

School Corporation
Number (see inst.)

City	
State	 Zip/Postal code	
				

Foreign country
2-character code

Enter the 2-digit county code numbers (found on the back of Schedule CT-40EZ) for the county where you lived and worked on January 1, 2015.
County where you lived

County where you worked

County where spouse lived

County where spouse worked

Round all entries

	
1.	 Enter your federal adjusted gross income from federal Form 1040EZ, line 4________________	1	00
2.	 Enter the amount from line 3 of the Indiana Deduction Worksheet on the back of this form_____	2	00
3.	 Subtract line 2 from line 1 and enter total____________________________________________	3	00
4.	 Enter $1,000 if filing a single return OR $2,000 if filing a joint return_______________________	4	00
5.	 Subtract line 4 from line 3 (if less than zero, leave blank)___________ State Taxable Income	

5	00

6.	 State adjusted gross income tax: multiply line 5 by 3.3% (.033) __________________________	6	00
7.	 County income tax (see instructions)_______________________________________________	7	00
8.	 Use tax due on out-of-state purchases (see instructions)_______________________________	8	00
9.	 Add lines 6, 7 and 8___________________________________________________ Total Tax	9	00

10.	 From W-2s: all Indiana state tax withheld___________________________________________	10	00
11.	 From W-2s: all Indiana county tax withheld__________________________________________	11	00
12.	 Add lines 10 and 11________________________________________________ Total Credits	12	00
13.	 If line 12 is more than line 9, subtract line 9 from line 12. This is an
overpayment. (If line 9 is more than line 12, skip to line 19.)________________ Overpayment	13	00
14.	

Amount from line 13 to be donated to the Indiana Nongame Wildlife Fund______________	14	00

00
16.	 Add lines 14 and 15. Enter total here (cannot be greater than line 13)______ Total Donations	16	
00
17.	 Subtract line 16 from line 13. This is your refund__________________________Your Refund	 17	00
15.	 Amount from line 13 to be donated to the Public K-12 Education Fund____________________	 15	

□ Checking □ Savings
b. Account Number	
□ Hoosier Works MC
d. Place an “X” in the box if refund will go to an account outside the United States □

18.	 a. Routing Number	

c.Type

Direct
Deposit

(see page 7)

19.	 If line 9 is more than line 12, subtract line 12 from line 9________________________________	19	00
20.	 Penalty if filed after due date (see instructions)_______________________________________	20	00
21.	 Interest if filed after due date (see instructions)_______________________________________	21	00
22.	 Add lines 19, 20 and 21. This is the amount you owe. See instructions for details on how to
make your payment, including credit card options. ____________________ Amount You Owe	22	00

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Indiana Deduction Worksheet
1.Renter’s deduction
Address where rented if different from the one on the front page (enter below)
	
Landlord’s name and address (enter below)			

	

Total amount of rent paid
$	

	

Number of months rented		

.	00

Enter the lesser of $3,000 OR total amount of rent paid______ 	1	

.	00

2. Enter the amount from line 7 of the unemployment compensation worksheet_____________________ 	2	

.00

3. Total deductions: Add lines 1 and 2. Carry this total to page 1, line 2____________________________ 	3	

.00

Extension of time to file
Place “X” in box if you have filed a federal extension of time to file, Form 4868
Place “X” in box if you have filed an Indiana extension of time to file, Form IT-9, or online via e-Pay.
Date of Death
If any individual listed at the top of the IT-40EZ died during 2015, enter date of death below (MMDD).

2015	

Taxpayer's date of death	
Authorization

2015

Spouse’s date of death	

Under penalty of perjury, I have examined this return and all attachments and to the best of my knowledge and belief, it is true, complete and correct. I
understand that if this is a joint return, any refund will be made payable to us jointly and each of us is liable for all taxes due under this return. Also, my
request for direct deposit of my refund includes my authorization to the Indiana Department of Revenue to furnish my financial institution with my routing
number, account number, account type, and Social Security number to ensure my refund is properly deposited. I give permission to the Department to
contact the Social Security Administration in order to confirm the Social Security number(s) used on this return are correct.
Your Signature						Date			

Daytime telephone number

Spouse’s Signature						Date
										Email address where we can reach you

I authorize the Department to discuss my return with my personal
representative.
Yes	
No	
If yes, complete the information below.
Personal Representative’s Name (please print)

Paid Preparer: Firm’s Name (or yours if self-employed)

	

IN-OPT on file with paid preparer if not filing electronically

PTIN
Telephone
number

Address

Address

City

City

State	
Zip Code	
Preparer's
signature__________________________________________________

State	

Zip Code

•	 If enclosing payment mail to: Indiana Department of Revenue, P.O. Box 7224, Indianapolis, IN 46207-7224.
•	 Mail all other returns to: Indiana Department of Revenue, P.O. Box 40, Indianapolis, IN 46206-0040.

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Keep a copy for your records.