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Form Unified Tax Credit for the Elderly
SC-40 2022
State Form 44404 Married Claimants Must File Jointly Due April 18, 2023
(R21 / 9-22)
Your Social Security Number
Your first name Initial Last name
Spouse’s first name Initial Last name
Spouse’s Social Security Number
Present address (number and street or rural route)
Taxpayer's date of death Spouse's date of death
City or Town State ZIP/Postal code
2022 2022
M M D D M M D D
1. Check box if you were age 65 or older by Dec. 31, 2022 Check box if spouse was age 65 or older by Dec. 31, 2022
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2. Were you a resident of Indiana for six months or more during 2022? Yes No
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3. Was your spouse a resident of Indiana for six months or more during 2022? Yes No
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Determine Your Income
Certain income, such as Social Security, veteran’s disability pensions and life insurance proceeds, should not be entered on this form.
Enter all other income received by you and your spouse during the tax year. Complete all spaces. If you had no income from any of the
sources listed below, place a zero (-0-) in the space provided. Round all entries.
A. Wages, salaries, tips and commissions, unemployment compensation, etc ............................. A 00
B. Dividend and interest income .................................................................................................... B 00
C. Net gain or loss from rental income, business income, etc ....................................................... C 00
D. Pensions or annuities (Do not enter Social Security benefits) .............................................. D 00
E. Total Income (Add Lines A through D and enter the total here) ............................................... E 00
F. Your Elderly Credit (See chart on back to figure your refund) ................................................ F 00
G. Your 2022 Additional Automatic Taxpayer Refund (See instructions) ....................................... G 00
H. Direct Deposit (1) Routing Number (3) Checking (4) Savings
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(2) Account Number
(5) Place an "X" in the box if refund will go to an account outside the United States.
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Under penalty of perjury, I (we) have examined this return and to the best of my (our) knowledge and belief, it is true, complete, and correct
and that I am (we are) not required to file an Indiana income tax return.
____________________________________________________ _______________________________________________
Your Signature Date Spouse's Signature Date
Daytime Telephone Number
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)
□ PTIN
__________________________________________________________
Telephone
number
Address ___________________________________________________ Address ___________________________________________________
City ______________________________________________________ City ______________________________________________________
State _______________________ ZIP Code __________________ State _______________________ ZIP Code __________________
*16222111694*
16222111694
