Schedule IN-H         Indiana Household Employment Taxes                                              Enclosure 
State Form 48684
(R17 / 9-23)                        Attach to Form IT-40 or Form IT-40PNR.                            Sequence No. 12
                                                                                        2023

             This schedule should be filed by an individual who:
               • withholds state and county (if applicable) tax on household employees, AND
               • pays those withholding taxes with the filing of his/her individual income tax return.

 Name of employer (as shown on individual income tax return)                Employer Social Security Number

                                                                            Federal Employer Identification Number
A  Did you file federal Schedule H for the tax year shown above?

             Yes.  Go to question B.

             No. Stop. Do not file this schedule.

B  Did you withhold state and/or county income tax for any household employee?

             Yes.  Complete Part II on the back of this schedule.

             No. Stop. Do not file this schedule.

C  Make sure you enclose the state copy of your employee's W-2 forms.

  Complete Part II (on page 2) first. Carry those totals to the Part I Summary below.

Part 1:               Summary of Household Employment Taxes

1.  Enter the total State Tax withheld from Part II, line 2  __________________________ 1                  .00

2.  Enter the total County Tax withheld from Part II, line 3   ________________________ 2                  .00

3.  Add lines 1 and 2. Enter the total here  _____________________________________      3                  .00
  Enter this amount on your Indiana individual income tax return on the following lines:
  •  Form IT-40 Schedule 4, line 2,
  •  Form IT-40PNR Schedule E, line 2.

Under penalties of perjury, I declare that I have examined this schedule, including accompanying statements and W-2 forms, 
and to the best of my knowledge and belief it is true, correct and complete.

___________________________________                ______________________                   ___________
Employer's signature                             Daytime telephone number                  Date

                                    *24100000000*
                                                 24100000000

 Part II: State and County Tax Withholding                     Line 4 - Enter the 2-digit county code from Indiana 
                                                               Departmental Notice #1 for which the line 3 county tax was 
Enter below the employee's name and Social Security number  withheld.
as it appears on his/her W-2 form. Attach additional pages if 
withholding for more than three household employees.           Summary -
                                                               ♦ Add all line 2 amounts and enter on Part I, line 1. 
Line 1 - Enter the amount on which you are withholding federal ♦ Add all line 3 amounts and enter on Part I, line 2.
income tax (also enter on W-2 boxes 16 and 18.)
                                                               Note: Get Form WH-4 and Departmental Notice #1 for detailed 
Line 2 - Enter the amount of Indiana state tax withheld (also 
                                                               information on how to calculate state and county withholding 
enter on W-2 box 17. Also, enter "IN" on W-2 box 15.) 
                                                               amounts and to get the county code numbers. This information 
                                                               is available on our web site at https://forms.in.gov/Download.
Line 3 - Enter the amount of county tax withheld (also enter 
                                                               aspx?id=2702 and www.in.gov/dor/files/reference/dn01.pdf
on W-2 box 19).

Employee Name (First, M.I., Last)                                             Employee Social Security Number

Income  __________________________________________________________________________        1                          .00

State Tax Withheld  ________________________________________________________________    2                            .00

County Tax Withheld  ______________________________________________________________       3                          .00

County Code Number (2-digit) _________________________________________________________      4

Employee Name (First, M.I., Last)                                             Employee Social Security Number

Income  __________________________________________________________________________        1                          .00

State Tax Withheld  ________________________________________________________________    2                            .00

County Tax Withheld  ______________________________________________________________       3                          .00

County Code Number (2-digit) _________________________________________________________      4

Employee Name (First, M.I., Last)                                             Employee Social Security Number

Income  __________________________________________________________________________        1                          .00

State Tax Withheld  ________________________________________________________________    2                            .00

County Tax Withheld  ______________________________________________________________       3                          .00

County Code Number (2-digit) _________________________________________________________      4

                                  *24100000000*
                                                      24100000000