Schedule H                   Schedule H Section 1: Residency Information                Enclosure                                            
   Form IT-40PNR                 (Complete Section 2: Additional Information on back)      Sequence No. 07
   State Form 54035                                                                   2022
   (R13 / 9-22)                                                                            Page 1 of 2
 Name(s) shown on Form IT-40PNR                                 Your Social Security Number

 Section 1: Residency   List all state(s) and dates of your (and your spouse’s, if filing jointly) residency during 2022. Enter 2-letter 
                        state name (e.g. “IL” for Illinois) or the letters “OC” if you were a resident of a foreign country (see instructions).
            Information
 Example
   State of     Date From             Date To               Did you file a tax return with the state/country? 
   Residence    (MM/DD)               (MM/DD)               Place “X” in appropriate box.

   IL               01  01      2022  06      01  2022      Yes X                     No

   IN               06  02      2022  12      31  2022      Yes X                     No

Your information
        (a)         (b)                  (c)
   State of     Date From             Date To               Did you file a tax return with the state/country? 
   Residence    (MM/DD)               (MM/DD)               Place “X” in appropriate box.

1A                              2022              2022      Yes                        No

1B                              2022              2022      Yes                        No

1C                              2022              2022      Yes                        No

1D                              2022              2022      Yes                        No

Spouse’s information if married filing jointly
   (a)              (b)                  (c)
   State of     Date From             Date To               Did you file a tax return with the state/country? 
   Residence    (MM/DD)               (MM/DD)               Place “X” in appropriate box.

2A                              2022              2022      Yes                        No

2B                              2022              2022      Yes                        No

2C                              2022              2022      Yes                        No

2D                              2022              2022      Yes                        No

                                                                                         Turn over to complete Section 2 

                                    *24022111694*
                                              24022111694

      Schedule H                              Schedule H Section 2:                                                          Enclosure          
      Form IT-40PNR                                                                                       Sequence No. 07A
                                              Additional Required Information                     2022                       Page 2 of 2

Section 2: Additional Information

1. Federal filing information
Are you filing a federal income tax return for 2022? Place “X” in appropriate box. Yes  No
                                                                              
2. 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. 

3. 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.

4. 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.

5. Date of death
If any individual listed at the top of the IT-40PNR 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-40PNR 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.

6. Your daytime                                          Your email
  telephone number                                       address

I authorize the Department to discuss my return with my personal   Paid Preparer: Firm’s Name (or yours if self-employed)
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 _______________________________________________

                                       *24022121694*
                                                                24022121694