Indiana Department of Revenue
                                                                             IT-6WTH
                                                                             For Use of Tax Year 2023
                                                                             08/2022

Cut on line before mailing

                                    IT-6WTH             0920    
XXXXXBusinessNameXXXXXXXXXXXXX
XXXXXAddressLine1XXXXXXXXXXXXX
XXXXXAddressLine2XXXXXXXXXXXXX                          Printed Name of Officer              Title

                                    6W
Federal ID Number         Due Date                      Signature of Officer                 Title
999 99 9999               99 99 9999
                                                        Date                    Daytime Phone
                          Calendar or Fiscal Year Ending
                          XXX 9999
                                                                                             Enter Total Tax Below

INDIANA DEPARTMENT OF REVENUE
P.O. BOX 6032
                                                                                                     .
INDIANAPOLIS, IN 46206-6032

                                    089999999999999990169999999999999999999