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04    Schedule 5 /                      Indiana Department of Revenue                                                Enclosure 
05    Schedule IN-DONATE                Schedule 5: Credits                                                Sequence No. 04
06    Form IT-40                                                                              2024
      State Form 53998 
07    (R15 / 9-24)
08 Name(s) shown on Form IT-40                                                            Your Social Security Number
09
10 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                        999           99 9999
11
12                                                                                                         Round all entries
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14 1.  Indiana state tax withheld: See instructions ___________________________________________         1  99999999999.00
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16 2.  Indiana county tax withheld: See instructions  _________________________________________         2  99999999999.00
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18 3.  Pass Through Entity Tax Credit  ____________________________________________________             3  99999999999.00
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20 4.  Estimated tax paid for 2024: include any extension payment made with Form IT-9  ____________     4  99999999999.00
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22 5. Unified tax credit for the elderly ____________________________________________________           5  99999999999.00
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24 6.  Earned income credit: enclose Schedule IN-EIC and enter amount from line A-3  _____________      6  99999999999.00
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26 7.  Lake County residential income tax credit ____________________________________________           7  99999999999.00
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28 8.  Economic development for a growing economy credit. Enter amount from Schedule IN-EDGE,  
29    line 19 (enclose schedule) ________________________________________________________               8  99999999999.00
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31 9.  Economic development for a growing economy retention credit. Enter amount from  
32    Schedule IN-EDGE-R, line 19 (enclose schedule) ______________________________________             9  99999999999.00
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34 10.  Headquarters relocation credit (refundable portion - see instructions) _______________________  10 99999999999.00
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36 11.  Adoption Credit _________________________________________________________________               11 99999999999.00
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38 12.  Reserved for future use __________________________________________________________              12 99999999999.00
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40 13.  Add lines 1 through 12. Enter total here and on Form IT-40, line 12 _____________ Total Credits 13 99999999999.00
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47                                      Schedule IN-DONATE
48                        Important: The amount on line 2 cannot exceed the amount on Form IT-40, line 16.
49
50 1.  Donations: List fund name, 3-digit code and amount to be donated (see instructions)
51
52    a.  Enter fund name XXXXXXXXXXXXXXXXXXXXXXXXXX                            code no.  999           1a 99999999999.00
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54    b.  Enter fund name XXXXXXXXXXXXXXXXXXXXXXXXXX                            code no.  999           1b 99999999999.00
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56    c.  Enter fund name XXXXXXXXXXXXXXXXXXXXXXXXXX                            code no.  999           1c 99999999999.00 
57
58 2.  Add lines 1a through 1c. Enter total here and on Form IT-40, line 17 _________ Total Donations   2  99999999999.00
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62                                      *23124111694*
63                                      23124111694
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