Schedule IN-DEP-A              Indiana Department of Revenue                                                       Enclosure 
      Form IT-40/IT-40PNR                                                                             Sequence No. 03B/04B
      State Form 53111               Adopted Dependent Information                                2024
      (R3 / 9-24)
Name(s) shown on Form IT-40/IT-40PNR                                                Your Social Security Number

      Adopted Dependent’s First Name Adopted Dependent’s Last Name

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

1C.                                  1D.   
1E. Place “X” in box if the first listed taxpayer is an adoptive parent of the child ____________________________  1E

1F. Place “X” in box if the spouse is an adoptive parent of the child _____________________________________   1F
      Adopted Dependent’s First Name Adopted Dependent’s Last Name

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

2C.                                  2D.   
2E. Place “X” in box if the first listed taxpayer is an adoptive parent of the child ____________________________  2E

2F. Place “X” in box if the spouse is an adoptive parent of the child _____________________________________   2F
      Adopted Dependent’s First Name Adopted Dependent’s Last Name

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

3C.                                  3D.   
3E. Place “X” in box if the first listed taxpayer is an adoptive parent of the child ____________________________  3E

3F. Place “X” in box if the spouse is an adoptive parent of the child _____________________________________   3F
      Adopted Dependent’s First Name Adopted Dependent’s Last Name

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

4C.                                  4D.   
4E. Place “X” in box if the first listed taxpayer is an adoptive parent of the child ____________________________  4E

4F. Place “X” in box if the spouse is an adoptive parent of the child _____________________________________   4F
      Adopted Dependent’s First Name Adopted Dependent’s Last Name

5A.                                  5B.   
      Adopted Dependent’s Social Security Number Adopted Dependent’s Date of Birth (mm dd yyyy)

5C.                                  5D.   
5E. Place “X” in box if the first listed taxpayer is an adoptive parent of the child ____________________________  5E

5F. Place “X” in box if the spouse is an adoptive parent of the child _____________________________________   5F

6.  Add the number of adopted dependents list above (see instructions). Enter the total here and  
    the box on line 6 of Schedule 3 (if filing Form IT-40) or Schedule D (if filing form IT-40PNR) _______________  Box 6

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