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Schedule 5 / Schedule IN-DONATE Schedule 5: Credits Enclosure
Form IT-40, State Form 53998 Sequence No. 04
(R13 / 9-22) 2022
Name(s) shown on Form IT-40 Your Social Security Number
Round all entries
1. Indiana state tax withheld: See instructions ___________________________________________ 1 .00
2. Indiana county tax withheld: See instructions _________________________________________ 2 .00
3. Estimated tax paid for 2022: include any extension payment made with Form IT-9 ____________ 3 .00
4. Unified tax credit for the elderly ____________________________________________________ 4 .00
5. Earned income credit: enclose Schedule IN-EIC and enter amount from line A-3 _____________ 5 .00
6. Lake County residential income tax credit ____________________________________________ 6 .00
7. Economic development for a growing economy credit. Enter amount from Schedule IN-EDGE,
line 19 (enclose schedule) ________________________________________________________ 7 .00
8. Economic development for a growing economy retention credit. Enter amount from
Schedule IN-EDGE-R, line 19 (enclose schedule) ______________________________________ 8 .00
9. Headquarters relocation credit (refundable portion - see instructions) _______________________ 9 .00
10. Adoption Credit ________________________________________________________________ 10 .00
11. 2022 Additional Automatic Taxpayer Refund: See instructions ____________________________ 11 .00
12. Add lines 1 through 11. Enter total here and on Form IT-40, line 12 _____________Total Credits 12 .00
Schedule IN-DONATE
Important: The amount on line 2 cannot exceed the amount on Form IT-40/IT-40PNR, line 16.
1. Donations: List fund name, 3-digit code and amount to be donated (see instructions)
a. Enter fund name code no. 1a .00
b. Enter fund name code no. 1b .00
c. Enter fund name code no. 1c .00
2. Add lines 1a through 1c. Enter total here and on Form IT-40/IT-40PNR, line 17 Total Donations 2 .00
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23122111694