Schedule IN-WH3                        Schedule IN-WH3: 
Form WH-3, State Form 53057
(9-22)                                 Indiana Withholding Statements
                                                                                      2022

Employer Name(s) shown on Form WH-3                                         Federal Employer Identification Number

       A                   B           C                        D           E         F            G
       Form Employee Identification    State                    State Tax   Local     Local Tax   Locality 
   Code          Number                Income                   Withheld    Income    Withheld    Code
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
   Add lines 1 through 25 in column D. Enter total on line 1 of 
26
   Form WH-3.
27 Add lines 1 through 25 in column F. Enter total on line 2 of Form WH-3.

                                       Schedule IN-WH3 Reference Chart
       Form Type             Form Code Form Type                Form Code   Form Type     Form Code
         W2/W2C              W         1099R                              R   1099G             U 
            W2G              G         1099M                              M   1099NEC           N

                                       *26222111694*
                                              26222111694

                    Instructions for Schedule IN-WH3: Indiana Withholding Statements

You must complete Schedule IN-WH3 when filing Form WH-3.               01 - ADAMS     32 - HENDRICKS  63 - PIKE
Enter information from each W-2 or 1099. If you have a 
withholding statement that withholds tax for multiple Indiana          02 - ALLEN     33 - HENRY      64 - PORTER
counties, enter the Indiana state income and Indiana state tax         03 - BARTHOLOMEW 34 - HOWARD   65 - POSEY
withheld once for that statement. Do not duplicate the Indiana         04 - BENTON    35 - HUNTINGTON 66 - PULASKI
state income and Indiana state tax withheld on multiple lines.
                                                                       05 - BLACKFORD 36 - JACKSON    67 - PUTNAM
Reminder: Any employer that files a combined total of more             06 - BOONE     37 - JASPER     68 - RANDOLPH
than 25 withholding statements is required to file those forms 
                                                                       07 - BROWN     38 - JAY        69 - RIPLEY
electronically.
                                                                       08 - CARROLL   39 - JEFFERSON  70 - RUSH
Column A, Form Code. Enter the appropriate form code listed            09 - CASS      40 - JENNINGS   71 - ST. JOSEPH
on the Reference Chart. Leave blank if a W-2 or 1099 form type is 
                                                                       10 - CLARK     41 - JOHNSON    72 - SCOTT
not listed.
                                                                       11 - CLAY      42 - KNOX       73 - SHELBY
Column B, Employee Identification Number. Enter the                    12 - CLINTON   43 - KOSCIUSKO  74 - SPENCER
employee’s Social Security number or recipient’s tax identification 
number.                                                                13 - CRAWFORD  44 - LAGRANGE   75 - STARKE
                                                                       14 - DAVIESS   45 - LAKE       76 - STEUBEN
Column C, State Income. Enter the amount of Indiana income.            15 - DEARBORN  46 - LAPORTE    77 - SULLIVAN
Column D, State Tax Withheld. Enter the amount of Indiana              16 - DECATUR   47 - LAWRENCE   78 - SWITZERLAND
State Tax withheld.                                                    17 - DEKALB    48 - MADISON    79 - TIPPECANOE
                                                                       18 - DELAWARE  49 - MARION     80 - TIPTON
Complete Columns E, F and G only if there is Indiana local 
withholding.                                                           19 - DUBOIS    50 - MARSHALL   81 - UNION
                                                                       20 - ELKHART   51 - MARTIN     82 - VANDERBURGH
Column E, Local Income. Enter the amount of Indiana local              21 - FAYETTE   52 - MIAMI      83 - VERMILLION
income.
                                                                       22 - FLOYD     53 - MONROE     84 - VIGO
Column F, Local Tax Withheld. Enter the amount of County Tax           23 - FOUNTAIN  54 - MONTGOMERY 85 - WABASH
withheld.                                                              24 - FRANKLIN  55 - MORGAN     86 - WARREN
Column G, Locality Code. Enter the appropriate Indiana 2-digit         25 - FULTON    56 - NEWTON     87 - WARRICK
county code.                                                           26 - GIBSON    57 - NOBLE      88 - WASHINGTON
                                                                       27 - GRANT     58 - OHIO       89 - WAYNE
Line 26. Add Column D, lines 1 through 25. Enter this total on line 
1 of Form WH-3.                                                        28 - GREENE    59 - ORANGE     90 - WELLS
                                                                       29 - HAMILTON  60 - OWEN       91 - WHITE
Line 27. Add Column F, lines 1 through 25. Enter this total on line    30 - HANCOCK   61 - PARKE      92 - WHITLEY
2 of Form WH-3.
                                                                       31 - HARRISON  62 - PERRY
Note. If you need more than 25 lines, complete and attach 
additional copies of Schedule IN-WH3 as needed, but do not 
complete line 26 or line 27. On the first schedule, enter the total of 
state tax withheld (Column D) from all pages on line 26 and enter 
the total of local tax withheld (Column F) from all pages on line 27. 
Use these totals numbers on lines 1 and 2 of Form WH-3.

                             *24100000000*
                                                              24100000000