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04       Schedule IN-DEP                      Indiana Department of Revenue                                                    Enclosure 
         Form IT-40/IT-40PNR                                                                                       Sequence No. 03A/04A
05       State Form 54815            Dependent Information and Additional 
06       (R13 / 9-24)                         Dependent Child Information
                                                                                           2024
07
08 Name(s) shown on Form IT-40/IT-40PNR                                                    Your Social Security Number
09
10 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                         999 99                        9999
11       Dependent’s First Name               Dependent’s Last Name
12
13 1A.   XXXXXXXXXXXXXXXXXXXX                 1B.   XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
14       Dependent’s Social Security Number   Dependent’s Date of Birth (mm dd yyyy)
15
16 1C.   999          99        9999          1D.   99 99         9999
17 1E.  Place “X” in box 1E if claiming dependent as an additional dependent child exemption ___________________  1E     X
18
19 1F. Place “X” in box 1F if dependent child claimed for the first time (see instructions) _______________________   1F X
20
21       Dependent’s First Name               Dependent’s Last Name
22
23 2A.   XXXXXXXXXXXXXXXXXXXX                 2B.   XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
24       Dependent’s Social Security Number   Dependent’s Date of Birth (mm dd yyyy)
25
26 2C.   999          99        9999          2D.   99 99         9999
27 2E.  Place “X” in box 2E if claiming dependent as an additional dependent child exemption ___________________  2E     X
28
29 2F. Place “X” in box 2F if dependent child claimed for the first time (see instructions) _______________________   2F X
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31       Dependent’s First Name               Dependent’s Last Name
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33 3A.   XXXXXXXXXXXXXXXXXXXX                 3B.   XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
34       Dependent’s Social Security Number   Dependent’s Date of Birth (mm dd yyyy)
35
36 3C.   999          99        9999          3D.   99 99         9999
37 3E.  Place “X” in box 3E if claiming dependent as an additional dependent child exemption ___________________  3E     X
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39 3F. Place “X” in box 3F if dependent child claimed for the first time (see instructions) _______________________   3F X
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41       Dependent’s First Name               Dependent’s Last Name
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43 4A.   XXXXXXXXXXXXXXXXXXXX                 4B.   XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
44       Dependent’s Social Security Number   Dependent’s Date of Birth (mm dd yyyy)
45
46 4C.   999          99        9999          4D.   99 99         9999
47 4E.  Place “X” in box 4E if claiming dependent as an additional dependent child exemption ___________________  4E     X
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49 4F. Place “X” in box 4F if dependent child claimed for the first time (see instructions) _______________________   4F X
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51 5.  Dependent Exemptions. Add the number of dependents listed above (see instructions). Enter the total  
52     here and in the box on line 2 of Schedule 3 (if filing Form IT-40) or Schedule D (if filing Form IT-40PNR) _____  Box 5  99
53
54 6.  Additional Dependent Exemptions. Add the total number of boxes with Xs from lines 1E,1F, 2E, 2F, 3E, 3F,  
55     4E and 4F if applicable. Enter the total here and in the box on line 3 of Schedule 3 (if filing Form IT-40) 
56     or Schedule D (if filing Form IT-40PNR) ________________________________________________________                  Box 6  99
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