01
0000000000111111111122222222223333333333444444444455555555556666666666777777777788888
1234567890123456789012345678901234567890123456789012345678901234567890123456789012345
04     Schedule H                                Indiana Department of Revenue                                                  Enclosure       
       Form IT-40PNR                                                                                                            Sequence No. 07
05     State Form 54035      Schedule H, Section 1: Residency Information                                      2024             Page 1 of 2
06     (R15 / 9-24)                    (Complete Section 2: Additional Information on back.)
07
08 Name(s) shown on IT-40PNR                                                   Your Social Security Number
09
10 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                             999                               99    9999
11
12 Section 1: Residency Information
13 List all state(s) and dates of your (and your spouse’s, if filing jointly) residency during 2024. Enter 2-letter state name  
14 (e.g. “IL” for Illinois) or the letters “OC” if you were a resident of a foreign country (see instructions).
15
16 Example
17     A                     B                      C                                                            D
18     State of              Date From              Date To                    Did you file a tax return with the state/country? 
19 Residence                 (MM/DD)                (MM/DD)                                 Place “X” in appropriate box.
20
21     IL               01   01      2024        06 01         2024                         Yes                X    No
22
23     IN               06   02      2024        12 31         2024                         Yes                X    No
24
25
26
27 Your Information
28     A                     B                      C                                                            D
29     State of              Date From              Date To                    Did you file a tax return with the state/country? 
30 Residence                 (MM/DD)                (MM/DD)                                 Place “X” in appropriate box.
31
32 1a. XX               99   99      2024        99 99         2024                         Yes                X    No X
33
34 1b. XX               99   99      2024        99 99         2024                         Yes                X    No X
35
36 1c. XX               99   99      2024        99 99         2024                         Yes                X    No X
37
38 1d. XX               99   99      2024        99 99         2024                         Yes                X    No X
39
40
41
42 Spouse’s Information if Married Filing Jointly
43     A                     B                      C                                                            D
44     State of              Date From              Date To                    Did you file a tax return with the state/country? 
45 Residence                 (MM/DD)                (MM/DD)                                 Place “X” in appropriate box.
46
47 2a. XX               99   99      2024        99 99         2024                         Yes                X    No X
48
49 2b. XX               99   99      2024        99 99         2024                         Yes                X    No X
50
51 2c. XX               99   99      2024        99 99         2024                         Yes                X    No X
52
53 2d. XX               99   99      2024        99 99         2024                         Yes                X    No X
54
55
56
57
58
59                                                                                                             Turn over to complete Section 2 
60
61
62                                     *24024111694*
63                                                  24024111694
64
65
66

01
0000000000111111111122222222223333333333444444444455555555556666666666777777777788888
1234567890123456789012345678901234567890123456789012345678901234567890123456789012345
04       Schedule H                              Indiana Department of Revenue                                                      Enclosure     
         Form IT-40PNR                                                                                         Sequence No. 07A
05       (continued)                             Schedule H, Section 2:                              2024                          Page 2 of 2
06                                       Additional Required Information
07
08 Section 2: Additional Information
09
10 1. Federal filing information
11 Are you filing a federal income tax return for 2024? Place “X” in appropriate box. Yes  X      No X
12
13 2. Extension of time to file
14    a.  Place “X” in box if you have filed a federal extension of time to file, Form 4868, or made an online extension payment.  X
15
16    b.  Place “X” in box if you have filed an Indiana extension of time to file, Form IT-9, or made an Indiana extension payment online. X
17
18 3.  Farm/Fishing income
19 Place “X” in box if at least two-thirds of your gross income was made from farming or fishing. X
20 Important: If you placed an “X” in the box, you MUST attach Schedule IT-2210.
21
22 4. Schedule IN-40PA filers.
23 If you are eligible to file federal Form 8857, Request for Innocent Spouse Relief, and are completing Indiana Schedule IN-40PA,         X
24 enclose Schedule IN-40PA and check the box. 
25
26 5.  Date of death
27 If any individual listed at the top of the IT-40PNR died during 2024, enter date of death (MM/DD).
28
29       Taxpayer’s date of death   99   99      2024             Spouse’s date of death   99        99 2024
30
31 6. Enter the number of days you worked in Indiana during this calendar year (see instructions).
32
33    You   999            Spouse   999
34
35 Authorization – Sign Form IT-40PNR after reading the following statement.
36 Under penalty of perjury, I have examined this return and all attachments and to the best of my knowledge and belief, it is true, 
   complete and correct. I understand that if this is a joint return, any refund will be made payable to us jointly and each of us is liable for 
37 all taxes due under this return. Also, my request for direct deposit of my refund includes my authorization to the Indiana Department of 
38 Revenue (DOR) to furnish my financial institution with my routing number, account number, account type and Social Security number to 
39 ensure my refund is properly deposited. I grant permission to DOR to contact the Social Security Administration to confirm that the
40 Social Security number(s) used on this return is correct.
41 7.  Your daytime                                               Your email 
42    telephone number     999999999999999                        address             XXXXXXXXXXXXXXXXXXXXXX
43
44
45 I authorize the Department to discuss my return with my        Paid Preparer: Firm’s Name (or yours if self-employed)
   personal representative.
46
47 Yes  X    No X    If yes, complete the information below.      XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
48
49 Personal Representative’s Name (please print)                   X         IN-OPT on file with paid preparer if not filing electronically
50
51 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                            PTIN                     999999999
52 Telephone 
53 number           9999999999                                    Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
54
55 Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                         City                XXXXXXXXXXXXXXXXXXXXXX
56
57 City        XXXXXXXXXXXXXXXXXXXXXX                             State               XX              ZIP Code 999999999
58                                                                Preparer’s 
59 State        XX              ZIP Code 999999999                signature
60
61
62                                       *24024121694*
63                                                                24024121694
64
65
66