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04     Schedule 3                                    Schedule 3: Exemptions                                        Enclosure 
05     Form IT-40, State Form 53997                                                                       Sequence No. 03
       (R14 / 9-23)                                                                                 2023
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07 Name(s) shown on Form IT-40                                                          Your Social Security Number
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09 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                999 99  9999
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   Complete and enclose Schedule IN-DEP: Dependent Information and Additional Dependent Child Information if you are claiming 
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   dependents on lines 2 and/or 3 below. Complete and enclose Schedule IN-DEP-A: Adopted Dependent Information if you are 
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   claiming dependents on line 6 below.
13                                                                                                        Round all entries
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15  1. Enter $2000 if you are married filing jointly; otherwise, enter $1000 ________________________   1 99999999999.00
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17  2. Enter the number of dependents listed on Schedule IN-DEP, Box 5      99   x $1000 _________      2 99999999999.00 
18  You MUST enclose Schedule IN-DEP.
19
20  3. You may claim an additional exemption for each qualifying dependent child:
21     • who is a son, stepson, daughter, stepdaughter, foster child and/or child for whom you are a  
22       legal guardian;
23     • who was under the age of 19 by Dec. 31, 2023; or
24     • who is a full-time student who was under the age of 24 by Dec. 31, 2023; and
25     • who you are eligible to claim as a dependent on line 2 above.
26
27  Enter the number of additional dependents
28  listed on Schedule IN-DEP, Box 6.                99  x $1500 ____________________________           3 99999999999.00
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30  4. Place “X” in box(es) below if, by Dec. 31, 2023
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32       You were age 65 or older    X and/or blind     X
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34       Spouse was 65 or older      X and/or blind     X
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36     Total number of boxes with Xs   99  x $1000 _____________________________________                4 99999999999.00 
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38
39  5. If age 65 or older, enter amount from Form IT-40, line 1. 99999999999999999999
40     • If filing as married filing separately and this amount is less than $20,000, place “X” in  
41       the “You were age 65 or older” box below. 
42     • For all other filers age 65 or older, if this amount is less than $40,000, place “X” in  
43       appropriate box(es) below. 
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45       You were age 65 or older    X
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47       Spouse was 65 or older      X
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49     Total number of boxes with Xs   99 x $500 _______________________________________              5   99999999999.00
50
51  6. Enter the number of additional adopted child  
52  exemptions listed on Schedule IN-DEP-A, Box 6       99       x $3000 ________________________     6   99999999999.00 
53  You MUST enclose Schedule IN-DEP-A.
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55  7. Add lines 1, 2, 3, 4, 5 and 6. Enter here and on Form IT-40, line 6 __________Total Exemptions   7 99999999999.00
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62                                     *23023111694*
63                                                               23023111694
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