Form                     Indiana Part-Year or Full-Year Nonresident 
           IT-40PNR
           State Form 472                          Individual Income Tax Return             2022
           (R21 / 9-22)         If filing for a fiscal year, enter the dates (see instructions) (MM/DD/YYYY):   Due April 18, 2023
                                                                                                                Place “X” in box
                                   from                           to:                                           if amending

     Your Social                                                  Spouse’s Social 
     Security Number                                              Security Number

                            Place “X” in box if applying for ITIN                     Place “X” in box if applying for ITIN
     Your first name                               Initial Last name                                            Suffix

     If filing a joint return, spouse’s first name Initial Last name                                            Suffix

     Present address (number and street or rural route) 
                                                                                                   Place “X” in box if you are 
                                                                                                   married filing separately.
     City                                                                    State          ZIP/Postal code

     Foreign country 2-character code (see instructions) 

     Enter below the 2-digit county code numbers (found on the back of Schedule CT-40PNR) for the county where you lived and 
     worked on Jan. 1, 2022.
     County where               County where                           County where         County where 
     you lived                  you worked                             spouse lived         spouse worked

                                                                                                                Round all entries
 1.  Complete Schedule A first. Enter here the amount from Section 3, line 36B, and enclose 
     Schedule A   ______________________________________________________ Indiana Income            1                             .00

 2.  Enter amount from Schedule B, line 6, and enclose Schedule B __________  Indiana Add-Backs    2                             .00

 3.  Add line 1 and line 2 _____________________________________________________________           3                             .00

 4.  Enter amount from Schedule C, line 12, and enclose Schedule C     ________ Indiana Deductions 4                             .00

 5.  Subtract line 4 from line 3 _________________________________________________________                    5                  .00

 6.  You must complete Schedule D. Enter amount from Schedule D, line 9,  
     and enclose Schedule D  ________________________________________Indiana Exemptions            6                             .00

 7.  Subtract line 6 from line 5 ______________________________ Indiana Adjusted Gross Income                 7                  .00
 8.  State adjusted gross income tax: multiply line 7 by 3.23% (.0323) 
     (if answer is less than zero, leave blank) _____________________   8                   .00
 9.  County tax. Enter county tax due from Schedule CT-40PNR 
     (if answer is less than zero, leave blank) _____________________   9                   .00

10.  Other taxes. Enter amount from Schedule E, line 5 (enclose sch.)    10                 .00

11.  Add lines 8, 9 and 10. Enter total here and on line 15 on the back _____________ Indiana Taxes  11                          .00

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12.  Enter credits from Schedule F, line 12 (enclose schedule)  ___                 12                          .00

13.  Enter offset credits from Schedule G, line 8 (enclose schedule)                13                          .00

14.  Add lines 12 and 13  _______________________________________________                                      Indiana Credits 14      .00

15.  Enter amount from line 11  __________________________________________                                     Indiana Taxes   15      .00

16.  If line 14 is equal to or more than line 15, subtract line 15 from line 14 (if smaller, skip to line 23)                  16      .00

17.  Enter donations from Schedule IN-DONATE (enclose schedule); cannot be greater than line 16                                17      .00

18.  Subtract line 17 from line 16 _________________________________________                                   Overpayment     18      .00

19.  Amount from line 18 to be applied to your 2023 estimated tax account (see instructions). 

        Enter your county code                    county tax to be applied __ $     a                           .00 

        Spouse’s county code                      county tax to be applied __ $     b                           .00 

        Indiana adjusted gross income tax to be applied __________ $                c                           .00

        Total to be applied to your estimated tax account (a + b + c; cannot be more than line 18)  _____                      19d     .00

20.  Penalty for underpayment of estimated tax from Schedule IT-2210 or IT-2210A  _____________                                20      .00

21.     Refund: Line 18 minus lines 19d and 20. Note: If less than zero, see line 23 instructions              Your Refund     21      .00

22.     Direct Deposit (see instructions) 

        a. Routing Number

        b. Account Number

        c. Type:            Checking               Savings              Hoosier Works MC

        d. Place an “X” in the box if refund will go to an account outside the United States

23.  If line 15 is more than line 14, subtract line 14 from line 15. Add to this any amount on line 20 
        (see instructions) ______________________________________________________________                                      23      .00

24.  Penalty if filed after due date (see instructions) _______________________________________                                24      .00

25.  Interest if filed after due date (see instructions) _______________________________________                               25      .00

26.     Amount Due: Add lines 23, 24 and 25  ______________________________                               Amount You Owe       26      .00
        Do not send cash. Please make your check or money order payable to:  
        Indiana Department of Revenue. See instructions if paying by credit card.

Sign and date this return after reading the Authorization statement on Schedule H. You must enclose Schedule H (both pages).

_____________________________________________________                                         _________________________________________________
Your Signature                                                     Date                      Spouse’s Signature                    Date

• If enclosing payment mail to: Indiana Department of Revenue, P.O. Box 7224, Indianapolis, IN 46207-7224. 
• Mail all other returns to: Indiana Department of Revenue, P.O. Box 40, Indianapolis, IN 46206-0040.

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