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04                                                                   IT-41                                           Indiana Department of Revenue
                                                                     2023 Schedule IN K-1
05                                                                   State Form 55891          Beneficiary’s Share of Indiana Adjusted Gross Income, 
                                                                     (R10 / 8-23)
06                                                                                                        Deductions, Modifications, and Credits
07
08                                                                                         Tax Year Beginning 99         99 9999            and Ending 99 99      9999
09
10                                                                   Name of Trust or Estate                                                              Federal Employer Identification Number
11
12                                                                   XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                          9999999999
13
14                                                                   Amended IN K-1   X        Final IN K-1 X             Nonresident Beneficiary X
15
                                    icallyically
16                                  nn                               Part 1 – Identification and Distribution Information
17                                                                   Provide a copy of this Schedule IN K-1 reflecting the beneficiary’s share of income, deductions, and credits to each beneficiary. Enclose 
18                                                                   a copy of each Schedule IN K-1 with the Form IT-41 return when filing. 
19                                  ctroctro
20                                  elle                             1. Beneficiary’s Name
21                                  e e
                                     
22                                  ee                               XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
23                                   l                               2. Beneficiary’s FEIN or Social Security Number        3. Beneficiary’s Address
24
25                                                                         9999999999                                       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
26                                                                   4. Beneficiary’s City                                  5. Beneficiary’s State     6. Beneficiary’s ZIP Code
27
28                                                                               XXXXXXXXXXXXXXXXXXXX                                       XX            999999999
29                                                                   7. Beneficiary’s Federal Pro Rata Percentage           8. Indiana County of Principal Employment 2-digit code
30
31                                                                    999.99          %                                     XX
32                                                                   9. Payer’s Name                                                                   10. Payer’s FEIN
33                                   IN K-1s must fil IN K-1s must fi
34                                   9 9
                                                                     XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                     99999999999
35                                  nn
36                                                                   11.  Pass Through Entity Tax_________________________________________________________        11   99999999999.00
37                                   tha tha
38                                  ee                               12.  IN State Tax Withheld ___________________________________________________________       12   99999999999.00
39
40                                                                   13.  IN County Tax Withheld  _________________________________________________________       13   99999999999.00
41
42
43                                  ith morith mor                   Part 2 - Pro Rata Share of Indiana Pass-through Tax Credits from Trust or Estate
44                                  ww
45                                  s s                                               Column A              Column B        Column C                   Column D
46                                  ee                                     IT-41 Federal ID Number          Certification   Certification/Project/PIN  Tax Credit      Column E
47                                                                               if Credit Is from IN K-1         Year      Number                        Code         Amount Claimed
48
49                                                                   1.          9999999999                   9999          9999999999999999              9999         99999999999.00
50
                                    d Estatd Estat                               9999999999                   9999          9999999999999999              9999         99999999999
51                                  nn                               2.                                                                                                              .00
52
53                                                                   3.          9999999999                   9999          9999999999999999              9999         99999999999.00
54
55                                                                   4.          9999999999                   9999          9999999999999999              9999         99999999999.00
56
57                                  Trusts aTrusts a                 5.          9999999999                   9999          9999999999999999              9999         99999999999.00
58
59
60
61
62                                                                                                            *24100000000* 
63                                                                                                                          24100000000
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65
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04
05
06
07 Part 3 - Distributive Share Amount (use the Indiana apportioned figures for the beneficiary)
08
09 1.  Interest income _______________________________________________________________                  1   99999999999.00
10
11 2.  Ordinary dividends ____________________________________________________________                  2   99999999999.00
12
13 3.  Net short-term capital gains  _____________________________________________________              3   99999999999.00
14
15 4.  Net long-term capital gains ______________________________________________________               4   99999999999.00
16
17 5.  Other portfolio and nonbusiness income  ___________________________________________              5   99999999999.00
18
19 6.  Ordinary business income  ______________________________________________________                 6   99999999999.00
20
21 7.  Net rental real estate income ____________________________________________________               7   99999999999.00
22
23 8.  Other rental income  ___________________________________________________________                 8   99999999999.00
24
25 9.  Directly apportioned deductions __________________________________________________               9   99999999999.00
26
27 10. Final year deductions __________________________________________________________                 10  99999999999.00
28
29 11. Total pro rata distributions (If lines 1-8 are positive, add them. If lines 1-8 are 
30     negative, see instructions. Also see instructions for reporting lines 9 and 10.)  ______________ 11  99999999999.00
31
32
33
34
35 Part 4 - State Modifications Add or subtract the following. Enter the distributive share amount of each modification for Indiana adjusted 
36 gross income. For nonresidents, apply apportioned figures. (Use a minus sign to denote negative amounts.)
37
38 1.  State income taxes deducted _____________________________________________________                1   99999999999.00
39
40 2.  Net bonus depreciation allowance _________________________________________________               2   99999999999.00
41
42 3.  Excess IRC Section 179 deduction ________________________________________________                3   99999999999.00
43
44 4.  Interest on U.S. obligations  ______________________________________________________             4   99999999999.00
45
46 5.  Add-back/Deduction  ________________________________________ Code No.                     999    5   99999999999.00
47
48 6.  Add-back/Deduction  ________________________________________ Code No.                     999    6   99999999999.00
49
50 7.  Add-back/Deduction  ________________________________________ Code No.                     999    7   99999999999.00
51
52 8.  Total distributive share of modifications (see instructions)   ______________________________    8   99999999999.00
53
54 9.  Add Part 3, line 11, to Part 4, line 8. See instructions for reporting on Schedule PTET,  
55     Schedule Composite, and/or Schedule Composite-COR  __________ Adjusted Gross Income               9  99999999999.00
56
57
58
59
60
61
62                                     *24100000000*
63                                                       24100000000
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