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04    Schedule 4               Indiana Department of Revenue                                                  Enclosure 
05    Form IT-40               Schedule 4: Other Taxes                                                  Sequence No. 03B
      State Form 56540                                                             2024
06    (R6 / 9-24)
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08 Name(s) shown on Form IT-40                                                     Your Social Security Number
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10 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                 999               99 9999
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15 1.  Use tax on out-of-state purchases from line 4 of Sales/Use Tax Worksheet __________________   1 99999999999.00
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17 2.  Household employment taxes. Enclose Schedule IN-H __________________________________          2 99999999999.00
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19 3. Recapture of certain Indiana offset credits. Enclose Schedule IN-CR _______________________    3 99999999999.00
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21 4.  Add lines 1 through 3. Enter here and on Form IT-40, line 10 ______________ Total Other Taxes 4 99999999999.00
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62                             *25924111694*
63                             25924111694
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