Indiana Additional Required Information (Nonresident)

Additional Required Information (Nonresident)
Schedule H
Schedule H Section 1: Residency Information

Schedule H

Form IT-40PNR

(Complete Section 2: Additional Information on back)

State Form 54035
(R14 / 9-23)

Name(s) shown on Form IT-40PNR								

Section 1: Residency
	Information
Example
	
State of
	Residence

Your Social Security Number

List all state(s) and dates of your (and your spouse’s, if filing jointly) residency during 2023. Enter 2-letter
state name (e.g. “IL” for Illinois) or the letters “OC” if you were a resident of a foreign country (see instructions).

Date From
(MM/DD)

Date To
(MM/DD)

	

IL	

01	01	2023	

	

IN	

06	

02	

2023	

Your information
(a)
State of
Residence

2023

Enclosure
Sequence No. 07
Page 1 of 2

(b)
Date From
(MM/DD)

Did you file a tax return with the state/country?
Place “X” in appropriate box.

06	01	 2023	Yes	
X	No
12	

31	

2023	Yes	
X	No

(c)
Date To
(MM/DD)

Did you file a tax return with the state/country?
Place “X” in appropriate box.

1A	

2023	

2023	

Yes		No

1B	

2023	

2023	

Yes		No

1C	

2023	

2023	

Yes		No

1D	

2023	

2023	

Yes		No

Spouse’s information if married filing jointly
(a)
State of
Residence

(b)
Date From
(MM/DD)

(c)
Date To
(MM/DD)

Did you file a tax return with the state/country?
Place “X” in appropriate box.

2A	

2023	

2023	

Yes		No

2B	

2023	

2023	

Yes		No

2C	

2023	

2023	

Yes		No

2D	

2023	

2023	

Yes		No

Turn over to complete Section 2

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Schedule H Section 2:
Additional Required Information

Schedule H

Form IT-40PNR

Section 2: Additional Information
1. Federal filing information
Are you filing a federal income tax return for 2023? Place “X” in appropriate box.	Yes

	

2023

Enclosure
Sequence No. 07A
Page 2 of 2

No

2. Extension of time to file
	 a. Place “X” in box if you have filed a federal extension of time to file, Form 4868, or made an online extension payment.
	 b. Place “X” in box if you have filed an Indiana extension of time to file, Form IT-9, or made an Indiana extension payment online.
3. Farm/Fishing income
Place “X” in box if at least two-thirds of your gross income was made from farming or fishing.
Important: If you placed an “X” in the box, you MUST attach Schedule IT-2210.
4. Schedule IN-40PA filers. If you are eligible to file federal Form 8857, Request for Innocent Spouse Relief, and are completing
Indiana Schedule IN-40PA, enclose Schedule IN-40PA and check the box.
5. Date of death
If any individual listed at the top of the IT-40PNR died during 2023, enter date of death (MM/DD).
	

Taxpayer’s date of death	

2023	

Spouse’s date of death	

2023

Authorization: Sign Form IT-40PNR after reading the following statement.
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 (DOR) 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 grant permission to DOR to contact the Social Security Administration to confirm that the
Social Security number(s) used on this return is correct.
6.	Your daytime	
	 telephone number	

Your email
address

I authorize the Department to discuss my return with my personal
representative.
	 Yes	

No	

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

If yes, complete the information below.

Personal Representative’s Name (please print)

	

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

PTIN
Telephone
number

Address

Address

City

City

State	

State	

ZIP Code

ZIP Code

Preparer’s
signature________________________________________________

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