Schedule                 Indiana Withholding and Composite 
        IN-COMPA
      State Form 52826                 Filing Opt-Out Affidavit
        (R3 / 8-23)

 Pass-Through Entity Information
 Name of Entity                                                         FEIN

 Address

 City, State, ZIP Code

Type of Pass-Through Entity:

       Partnership               S Corporation         Estate      Trust
 □                          □                   □                □
 Nonresident Information
 Name                                                                   FEIN/SSN

 Address

 City, State, ZIP Code

 Type of Entity

 Year(s) (see instructions)

Please check the reason(s) for claiming an exemption for, or reduction in the amount of withholding:

  The entity is an employee stock ownership plan. (03)
□
  The entity is an insurance company not subject to adjusted gross income tax or financial institutions tax. (05)
□
  The entity is a nonprofit (including IRAs and other retirement plans) and the income is not unrelated business 
□
  income to the entity. (06)

  The entity is a real estate investment trust. Do not claim this exemption if the entity is a captive real estate 
□
  investment trust. (07)

  The entity is a real estate mortgage investment conduit. (08)
□
  The entity is permitted a treaty-based exemption from income tax. Please list the country and the relevant 
□
  provision of the treaty (if known). (09) ____________________________

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  The income is subject to reduction because the entity claiming ownership has an allowable loss to be  
□
 applied against the income.

    Suspended losses (list amount allowable) (04)             ______________
 □
 
  Claimed                                                     ______________

    Passive activity losses (list amount allowable) (10)      ______________
 □
 
  Claimed                                                     ______________

    Indiana net operating losses (list amount allowable) (11) ______________
 □
  Claimed                                                     ______________

  The tax owed by the entity is reduced by either Indiana credit carryforwards or Indiana credits from other  
□
 sources. List the credit, amount, the year in which the credit was earned, and the FEIN or Social Security  
 number of the source. (12)

  Credit                                       Year           FID of 
                Amount
 (3-digit code)                                Earned         Source

  The entity is a corporation or financial institution that is registered with the Indiana Secretary of State to  
□
 do business in Indiana and is remitting estimated payments on the income from the pass-through entity.  
 List the FID if the corporation otherwise subject to withholding is different than the corporation reporting  
 the tax for Indiana purposes. (13) _________________________

Under penalties of perjury, I understand that I am responsible for filing any Indiana tax returns and remitting 
any tax due as a result of the pass-through entity’s income derived from Indiana sources. I further agree 
that I consent to the jurisdiction of the state of Indiana with regard to any income, return filing, assessment, 
and rights of appeal. I further agree that this waiver of withholding does not apply if a partnership is subject 
to adjustments resulting from Indiana or federal adjustments, including audits, administrative adjustment 
requests, and amended returns. This agreement may be revoked at any time by the Indiana Department of 
State Revenue (“Department”), and the Department may notify the pass-through entity listed above of the 
revocation and any disallowance of waivers. 

Name: _________________________________        Name (printed): _________________________

Title (if applicable): _______________________ Date: ________________________________

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                                Instructions for Indiana Withholding and 
                                Composite Filing Opt-Out Affidavit

The Schedule IN-COMPA is intended as a schedule to             Nonresident Information
permit a shareholder, partner, or beneficiary to have 
nonresident tax withholding reduced or eliminated in           Enter all fields for the affected nonresident. For type 
certain cases. These cases are intended to be those            of entity, use a common description (e.g., individual, S 
circumstances where an ultimate taxpayer would have an         corporation, C corporation, etc.).
Indiana income tax liability that is significantly lower than 
the amount required to be withheld or withholding would        For the year, enter the first year and last year of the 
result in duplicate collection of the same tax.                election (for instance, 2022-2026 or 2022-forward) only for 
                                                               the first five reasons listed in the affidavit or for the reason 
This affidavit may not be used to claim a reduction or         associated with corporations registered in Indiana and 
waiver of pass through entity tax ("PTET"). Any tax required  remitting estimated payments. For all other listed reasons, 
to be withheld will be reduced by the PTET even if this        enter only the current taxable year.
affidavit is not completed.
                                                               If multiple tax years are entered appropriately, the affidavit 
A pass-through entity is not required to accept the affidavit. generally is required to be completed only once for the 
If a pass-through entity does not accept this affidavit,       entire period specified unless the department specifically 
withholding is required in the same manner as if no affidavit  voids the affidavit. However, if there is a material change 
had been completed. In addition, the department may void       in law (as published in the Indiana Register) or material 
any affidavit and may require a pass-through entity to not     change in fact, the listing of multiple years is void upon 
accept an affidavit upon notification by the department.       such material change.

For a pass-through entity, any completed affidavits are        Reasons for Claiming Exemption or Reduction in 
required to be attached to the pass-through entity’s return    Withholding
each year for which the affidavit applies. Failure to attach 
an affidavit shall be treated as if the affidavit had not      Please check at least one box specifying a reason for 
been completed for that taxable year and composite             reduced or eliminated withholding. More than one box can 
tax will be assessed.                                          be checked.

For a partner, shareholder, or beneficiary, the affidavit      Each box has a number in parentheses after the 
may be attached to the return. However, attachment is not      explanation. The pass-through entity is required to list the 
required. The partner, shareholder, or beneficiary must        code in Column A on the line of Schedule Composite or 
provide a completed copy of the affidavit upon department      Schedule Composite-COR associated with the nonresident 
request.                                                       completing this affidavit. If more than one box is checked, 
                                                               the pass-through entity is required to list one of the 
The affidavit must be completed by the nonresident before      allowable codes in Column A of the Schedule Composite or 
the 15th day of the fourth month following the end of the      Schedule Composite-COR.
pass-through entity’s tax year. In the case of an affidavit 
covering multiple years, failure to complete the affidavit in  If you are claiming an exemption because of an allowable 
a timely manner will result in the affidavit being treated as  loss, you are required to specify each amount of loss that 
void for that taxable year.                                    is potentially applicable against the income from the pass-
                                                               through entity.
IMPORTANT: In the event of an amended return by the 
pass-through entity or a department adjustment to              If you are claiming that you have a credit that (1) is from 
the pass-through entity, this affidavit will not relieve       another entity or (2) is a carryforward from a previous year, 
the pass-through entity of withholding based on the            regardless of whether the credit was generated by this 
amended return. Further, this affidavit cannot be used         pass-through entity, list each credit separately. Use the 
to relieve a partnership of any tax otherwise due as           three-digit code assigned to the credit by the department. 
a result of adjustments if the partnership elects to be        A list of available credits for a nonresident can be found in 
taxed at the partnership level.                                the relevant instruction booklet for the nonresident’s normal 
                                                               return filing.

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