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
      (R12 / 9-23)
                                                                                                                       2023
 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 1E if claiming dependent as an additional dependent child exemption _________________ 1E

  1F.  Place “X” in box 1F if dependent child claimed for the first time (see instructions) _____________________ 1F
 
      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 2E if claiming dependent as an additional dependent child exemption _________________ 2E

  2F.  Place “X” in box 2F if dependent child claimed for the first time (see instructions) _____________________ 2F
 
      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 3E if claiming dependent as an additional dependent child exemption _________________ 3E

  3F.  Place “X” in box 3F if dependent child claimed for the first time (see instructions) _____________________ 3F
 
      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 4E if claiming dependent as an additional dependent child exemption _________________ 4E

  4F.  Place “X” in box 4F if dependent child claimed for the first time (see instructions) _____________________ 4F

  5. 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 5

  6. Additional Dependent Exemptions. Add the total number of boxes with Xs from lines 1E,1F, 2E, 2F, 3E, 3F,  
 4E and 4F 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 6

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