Schedule 3                                    Schedule 3: Exemptions                                        Enclosure 
    Form IT-40, State Form 53997                                                                       Sequence No. 03
    (R13 / 9-22)                                                                                 2022

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

Complete and enclose Schedule IN-DEP: Dependent Information and Additional Dependent Child Information if you are claiming 
dependents on lines 2 and/or 3 below. Complete and enclose Schedule IN-DEP-A: Adopted Dependent Information if you are 
claiming dependents on line 6 below.
                                                                                                       Round all entries

 1. Enter $2000 if you are married filing jointly; otherwise, enter $1000 ________________________   1                  .00

 2. Enter the number of dependents listed on Schedule IN-DEP, Box 6           x $1000 _________      2                  .00 
 You MUST enclose Schedule IN-DEP.

 3. You may claim an additional exemption for each qualifying dependent child:
    • who is a son, stepson, daughter, stepdaughter, foster child and/or child for whom you are a  
      legal guardian;
    • who was under the age of 19 by Dec. 31, 2022; or
    • who is a full-time student who was under the age of 24 by Dec. 31, 2022; and
    • who you are eligible to claim as a dependent on line 2 above.

 Enter the number of additional dependents
 listed on Schedule IN-DEP, Box 7.                 x $1500 ____________________________              3                  .00

 4. Place “X” in box(es) below if, by Dec. 31, 2022

      You were age 65 or older      and/or blind

        Spouse was 65 or older      and/or blind

    Total number of boxes with Xs    x $1000 _____________________________________                   4                  .00 

 5. If age 65 or older, enter amount from Form IT-40, line 1.
    • If filing as married filing separately and this amount is less than $20,000, place “X” in  
      the “You were age 65 or older” box below. 
    • For all other filers age 65 or older, if this amount is less than $40,000, place “X” in  
      appropriate box(es) below. 

      You were age 65 or older 

        Spouse was 65 or older

    Total number of boxes with Xs   x $500 _______________________________________                 5                    .00

 6. Enter the number of additional adopted child  
 exemptions listed on Schedule IN-DEP-A, Box 6               x $3000 ________________________      6                    .00 
 You MUST enclose Schedule IN-DEP-A.

 7. Add lines 1, 2, 3, 4, 5 and 6. Enter here and on Form __________IT-40, lineTotal6Exemptions    7                    .00

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