Schedule                     Indiana Department of Revenue
      IN-40SA                      Indiana Injured Spouse 
      State Form 50509
      (R7 / 6-22)                  Allocation Schedule                                                 Year of Claim ___________

   Are You an Injured Spouse?

   You are an injured spouse if you file a joint Indiana individual income tax return and all or part of your share of the overpayment 
   was, or is expected to be, applied (offset) against your spouse’s past-due debt: Indiana state and/or county tax; federal income 
   tax; Child Support; FSSA; Workforce Development; Purdue University; Ivy Tech Community College; Indiana State University; 
   Vincennes University; Indiana University; Department of Transportation; Trial Court Technology and/or Association of Indiana 
   Counties.

   Complete this form if all three of the following apply and you want your share of the overpayment shown on the joint return 
   refunded to you.
   1. You are not required to pay the past-due amount;
   2. You reported income such as wages, taxable interest, etc. on the joint return; and
   3. You made and reported payments and/or credits, such as Indiana state and/or county tax withheld from your wages, estimated
      taxpayments, the earned income credit, or other refundable credit(s) on the joint Indiana return.

   Required Attachments
   You must attach a copy of the following information to this schedule:
   1. Your federal income tax return (Form 1040 or 1040-SR), and
   2. All W-2 forms of both spouses and any other forms (1099, IN K-1, etc.) showing state/county income tax withheld.

Note: Your claim cannot be processed if you do not submit this required information.

Part 1 - Information About the Joint Tax Return for Which This Claim is Filed

1. Enter the following information exactly as it is shown on the tax return for which you are filing this claim. The spouse’s name and
   Social Security number shown first on that tax return must also be shown first below.
First name, initial, and last name shown first on the return                   Social Security number  Check here if 
                                                                                        shown first    Injured Spouse

                                                                                                                    □
First name, initial, and last name shown second on the return                  Social Security number  Check here if 
                                                                                     shown second      Injured Spouse

                                                                                                                    □

2. Enter Your current home address.
Street Address                                               City                           State      ZIP Code

3. Is the address on your joint return different from the address shown above?       Yes  No
                                                                               □         □

                                   *24100000000*
                                                             24100000000

Part 2 - Allocation Between Spouses of Items on the Joint Indiana Individual Income Tax Return

                                                                       (a)              (b)           (c)
                                                               Amount shown on    Amount allocated to Amount allocated to 
                                                               joint federal and    injured spouse    other spouse
Allocated Items                                                Indiana tax returns
4.  Income. Enter the separate income that each spouse 
     earned. Allocate joint income, such as interest earned 
     on a joint bank account, as you determine. Be sure to 
     allocate all income shown on the joint tax return.
     a.  Wages
     b.  All other income. Identity the type and amount:
     _____________________________________________
     _____________________________________________
     _____________________________________________
5.  Adjustments claimed on your federal tax return. 
     Enter each spouse’s separate adjustments, such as an 
     IRA deduction. Allocate other adjustments claimed on 
     your federal return as you determine.
6.  Indiana Tax Add-Backs. Enter each spouse’s share of   
     tax add-backs from Schedule 1/B, and identify:

     Allocate each add-back       code no.              
     claimed on your Indiana      code no.              
     return as you determine. 
                                  code no.   

7.  Indiana Deductions. Enter each spouse’s share of 
     deductions from Schedule 2/C, and identify:

     Allocate each deduction      code no.              
     claimed on your Indiana 
     return as you determine.     code no.              
                                  code no.   

8.  Number of exemptions. Allocate the exemptions 
     claimed on the joint Indiana return to the spouse who 
     would have claimed them if separate returns had been 
     filed. Enter whole numbers only (for example, you cannot 
     allocate 3 exemptions by giving 1.5 exemptions to each 
     spouse). Show the division of exemptions by type, 
     such as 2 exemptions claimed on Indiana return plus 1 
     additional exemption for certain dependent child.
9.  Withholding credits. Enter Indiana state and county tax 
     withheld from each spouse’s income as shown on the 
     W-2s, 1099-Rs, W-2Gs, etc. Be sure to attach copies of 
     these forms to this schedule.
10.  Credits. Allocate any Indiana earned income credit to the 
     spouse who was allocated the dependent’s exemption. 
     Allocate all other Indiana credits based on each spouse’s 
     interest.
11.  Payments. Allocate joint estimated tax payments as you 
     determine.

Note: The Indiana Department of Revenue will figure the amount of any refund due the injured spouse.

                                          *24100000000*
                                                            24100000000

Part 3   - Signature Area
Under penalties of perjury, I declare that I have examined this form and any accompanying schedules or statements and to the best of 
my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information 
of which preparer has any knowledge.

Injured Spouse’s                                                                   Phone
Signature:  ________________________________________________   Date: _____________   Number: _____________________

Paid Preparer’s Use Only

Preparer’s
Signature:  ________________________________________________   Date: _____________  Check if self-employed:   
                                                                                                           □

Preparer’s SSN or PTIN: __________________________

Mail your completed claim to:

Indiana Department of Revenue  
Returns Processing and Operations  
P. O. Box 7207 
Indianapolis, IN 46207-7207

Or, Fax it to 317-974-1605.

                                    *24100000000*
                                                   24100000000