Schedule IN-DEP                      Indiana Department of Revenue                                                   Enclosure 
      Form IT-40/IT-40PNR                                                                                       Sequence No. 03A/04A
      State Form 54815       Dependent Information and Additional 
      (R13 / 9-24)                         Dependent Child Information
                                                                                        2024

Name(s) shown on Form IT-40/IT-40PNR                                                    Your Social Security Number

      Dependent’s First Name               Dependent’s Last Name

1A.                                        1B.   
      Dependent’s Social Security Number   Dependent’s Date of Birth (mm dd yyyy)

1C.                                        1D.   
1E.  Place “X” in box 1E if claiming dependent as an additional dependent child exemption ___________________  1E

1F. Place “X” in box 1F if dependent child claimed for the first time (see instructions) _______________________   1F

      Dependent’s First Name               Dependent’s Last Name

2A.                                        2B.   
      Dependent’s Social Security Number   Dependent’s Date of Birth (mm dd yyyy)

2C.                                        2D.   
2E.  Place “X” in box 2E if claiming dependent as an additional dependent child exemption ___________________  2E

2F. Place “X” in box 2F if dependent child claimed for the first time (see instructions) _______________________   2F

      Dependent’s First Name               Dependent’s Last Name

3A.                                        3B.   
      Dependent’s Social Security Number   Dependent’s Date of Birth (mm dd yyyy)

3C.                                        3D.   
3E.  Place “X” in box 3E if claiming dependent as an additional dependent child exemption ___________________  3E

3F. Place “X” in box 3F if dependent child claimed for the first time (see instructions) _______________________   3F

      Dependent’s First Name               Dependent’s Last Name

4A.                                        4B.   
      Dependent’s Social Security Number   Dependent’s Date of Birth (mm dd yyyy)

4C.                                        4D.   
4E.  Place “X” in box 4E if claiming dependent as an additional dependent child exemption ___________________  4E

4F. Place “X” in box 4F if dependent child claimed for the first time (see instructions) _______________________   4F

5.  Dependent Exemptions. Add the number of dependents listed above (see instructions). Enter the total  
    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

6.  Additional Dependent Exemptions. Add the total number of boxes with Xs from lines 1E,1F, 2E, 2F, 3E, 3F,  
    4E and 4F if applicable. Enter the total here and in the box on line 3 of Schedule 3 (if filing Form IT-40) 
    or Schedule D (if filing Form IT-40PNR) ________________________________________________________                  Box 6

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