Schedule IN-DEP     Schedule IN-DEP: Dependent Information and Additional                                                                                 Enclosure 
      Form IT-40/IT-40PNR                                                                                     Sequence No. 03A/04A
      State Form 54815                   Dependent Child Information
      (R11 / 9-22)
                                                                                                                                                                2022
 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 if claiming dependent as an additional dependent child exemption  ___________________ 1E
 
      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 if claiming dependent as an additional dependent child exemption  ___________________ 2E
 
      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 if claiming dependent as an additional dependent child exemption  ___________________ 3E

      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 if claiming dependent as an additional dependent child exemption  ___________________ 4E

      Dependent’s First Name                 Dependent’s Last Name
 
  5A.                                    5B.
      Dependent’s Social Security Number     Dependent’s Date of Birth (mm dd yyyy)
 
  5C.                                    5D. 
  5E.  Place “X” in box if claiming dependent as an additional dependent child exemption  ___________________ 5E

  6. 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 6

  7. Additional Dependent Exemptions. Add the total number of boxes with Xs from lines 1E, 2E, 3E, 4E, 
 and 5E, 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 7

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