Schedule 7                   Schedule 7: Additional Required Information                                               Enclosure 
      Form IT-40, State Form 54000                                                                     Sequence No. 06
      (R13 / 9-22)                                                                             2022

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

1. Federal filing information
Are you filing a federal income tax return for 2022? Place “X” in appropriate box. Yes No
                                                                                 
2. Out-of-state income: Complete if you and/or your spouse (if filing a joint return) received any salary, wage, tip and/or commission 
income from Illinois, Kentucky, Michigan, Ohio, Pennsylvania or Wisconsin. Enter two-digit code number from the back of Schedule CT-40 
for state where you and/or your spouse worked.
State where you worked             Your income                   State where spouse worked      Spouse’s income

                             $                        .00                                      $                             .00
3. Extension of time to file
  a. Place “X” in box if you have filed a federal extension of time to file, Form 4868, or made an online extension payment. 
 
  b. Place “X” in box if you have filed an Indiana extension of time to file, Form IT-9, or made an Indiana extension payment online. 

4. Farm/Fishing income
Place “X” in box if at least two-thirds of your gross income was made from farming or fishing.
Important: If you placed an “X” in the box, you MUST attach Schedule IT-2210.
5. Schedule IN-40PA filers. If you are eligible to file federal Form 8857, Request for Innocent Spouse Relief, and are completing
Indiana Schedule IN-40PA, enclose Schedule IN-40PA and check the box.

6. Date of death
If any individual listed at the top of the IT-40 died during 2022, enter date of death (MM/DD).
 
      Taxpayer’s date of death                        2022 Spouse’s date of death              2022
Authorization: Sign Form IT-40 after reading the following statement.
Under penalty of perjury, I have examined this return and all attachments and to the best of my knowledge and belief, it is true, com-
plete and correct. I understand that if this is a joint return, any refund will be made payable to us jointly and each of us is liable for all 
taxes due under this return. Also, my request for direct deposit of my refund includes my authorization to the Indiana Department of 
Revenue (DOR) to furnish my financial institution with my routing number, account number, account type and Social Security number to 
ensure my refund is properly deposited. I grant permission to DOR to contact the Social Security Administration to confirm that the
Social Security number(s) used on this return is correct.

7. Your daytime                                              Your
  telephone number                                           email address 

I authorize the Department to discuss my return with my          Paid Preparer: Firm’s Name (or yours if self-employed)
personal representative.
  Yes    No        If yes, complete the information below. 

Personal Representative’s Name (please print)                              IN-OPT on file with paid preparer if not filing electronically

                                                                 PTIN
Telephone
number                                                           Address

Address                                                          City

City                                                             State                         ZIP Code
                                                                 Preparer’s
State                         ZIP Code                           signature _________________________________________

                                       *23322111694*
                                                             23322111694