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04               Form                   Indiana Part-Year or Full-Year Nonresident 
            IT-40PNR
05            State Form 472                      Individual Income Tax Return                 2023
06            (R22 / 9-23)         If filing for a fiscal year, enter the dates (see instructions) (MM/DD/YYYY):   Due April 15, 2024
07                                                                                                                 Place “X” in box
08                                 from 99        99       9999     to:   99       99         9999                 if amending      X
09
10  Your Social                                                    Spouse’s Social 
11  Security Number          999        99        9999             Security Number     999     99                  9999
12
13                         X Place “X” in box if applying for ITIN                     X Place “X” in box if applying for ITIN
14  Your first name                               Initial  Last name                                                     Suffix
15
16            XXXXXXXXXXXXXXX                      X       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                     XXXXX
17  If filing a joint return, spouse’s first name Initial  Last name                                                     Suffix
18
19            XXXXXXXXXXXXXXX                      X       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                     XXXXX
20  Present address (number and street or rural route) 
21                                                                                                    Place “X” in box if you are 
22                         XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                             married filing separately.    X
23  City                                                                  State                ZIP/Postal code
24
25                XXXXXXXXXXXXXXXXXXXX                                          XX                 9999999999
26  Foreign country 2-character code (see instructions) 
27
28      XX
29
30  Enter below the 2-digit county code numbers (found on the back of Schedule CT-40PNR) for the county where you lived and 
31  worked on Jan. 1, 2023.
32  County where                   County where                           County where         County where 
33  you lived         99           you worked     99                      spouse lived   99    spouse worked           99
34
35                                                                                                                 Round all entries
36  1.  Complete Schedule A first. Enter here the amount from Section 3, line 36B, and enclose 
37      Schedule A ______________________________________________________ Indiana Income              1            99999999999.00
38
39  2.  Enter amount from Schedule B, line 6, and enclose Schedule B __________  Indiana Add-Backs    2            99999999999.00
40
41  3.  Add line 1 and line 2 _____________________________________________________________           3            99999999999.00
42
43  4.  Enter amount from Schedule C, line 12, and enclose Schedule C  ________ Indiana Deductions    4            99999999999.00
44
45  5.  Subtract line 4 from line 3 _________________________________________________________         5            99999999999.00
46
47  6.  You must complete Schedule D. Enter amount from Schedule D, line 9,  
48      and enclose Schedule D  ________________________________________Indiana Exemptions            6            99999999999.00
49
50  7.  Subtract line 6 from line 5 ______________________________ Indiana Adjusted Gross Income                 7 99999999999.00
51  8.  State adjusted gross income tax: multiply line 7 by 3.15% (.0315) 
52      (if answer is less than zero, leave blank) _____________________   8    99999999999    .00
53  9.  County tax. Enter county tax due from Schedule CT-40PNR 
54      (if answer is less than zero, leave blank) _____________________   9    99999999999    .00
55
56 10.  Other taxes. Enter amount from Schedule E, line 5 (enclose sch.)    10  99999999999    .00
57
58 11.  Add lines 8, 9 and 10. Enter total here and on line 15 on the back _____________ Indiana Taxes  11         99999999999.00
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05 12.  Enter credits from Schedule F, line 13 (enclose schedule)  ___     12      99999999999.00
06
07 13.  Enter offset credits from Schedule G, line 8 (enclose schedule)    13      99999999999          .00
08
09 14.  Add lines 12 and 13  _______________________________________________                     Indiana Credits   14   99999999999.00
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11 15.  Enter amount from line 11  __________________________________________                    Indiana Taxes     15   99999999999.00
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13 16.  If line 14 is equal to or more than line 15, subtract line 15 from line 14 (if smaller, skip to line 23)   16   99999999999.00
14
15 17.  Enter donations from Schedule IN-DONATE (enclose schedule); cannot be greater than line 16                 17   99999999999.00
16
17 18.  Subtract line 17 from line 16 _________________________________________                  Overpayment       18   99999999999.00
18
19 19.  Amount from line 18 to be applied to your 2024 estimated tax account (see instructions). 
20
21      Enter your county code    99        county tax to be applied __ $  a       99999999999          .00 
22
23      Spouse’s county code      99        county tax to be applied __ $  b       99999999999          .00 
24
25      Indiana adjusted gross income tax to be applied __________ $       c       99999999999          .00
26
27      Total to be applied to your estimated tax account (a + b + c; cannot be more than line 18)  _____           19d 99999999999.00
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29 20.  Penalty for underpayment of estimated tax from Schedule IT-2210 and IT-2210A  ____________                 20   99999999999.00
30
31      a. Enter code A if annualizing. Enter Code F if Farmer or Fisherman  ___________         a      X
32
33 21.  Refund: Line 18 minus lines 19d and 20. Note: If less than zero, see line 23 instructions ____ Your Refund 21   99999999999.00
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35 22.  Direct Deposit (see instructions) 
36
37      a. Routing Number      9 9 9 9 9 9 9 9 9
38
39      b. Account Number      9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9
40
41      c. Type:   X  Checking         X     Savings X        Hoosier Works MC
42
43      d. Place an “X” in the box if refund will go to an account outside the United States           X
44
45 23.  If line 15 is more than line 14, subtract line 14 from line 15. Add to this any amount on line 20 
46      (see instructions) ______________________________________________________________                          23   99999999999.00
47
48 24.  Penalty if filed after due date (see instructions) _______________________________________                 24   99999999999.00
49
50 25.  Interest if filed after due date (see instructions) _______________________________________                25   99999999999.00
51
52 26.  Amount Due: Add lines 23, 24 and 25  ______________________________                      Amount You Owe    26   99999999999.00
53      Do not send cash. Please make your check or money order payable to:  
54      Indiana Department of Revenue. See instructions if paying by credit card.
55
   Sign and date this return after reading the Authorization statement on Schedule H. You must enclose Schedule H (both pages).
56
57 _____________________________________________________                         _________________________________________________
58 Your Signature                                          Date                 Spouse’s Signature                      Date
59 • If enclosing payment mail to: Indiana Department of Revenue, P.O. Box 7224, Indianapolis, IN 46207-7224. 
60 • Mail all other returns to: Indiana Department of Revenue, P.O. Box 40, Indianapolis, IN 46206-0040.
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