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04     Schedule 5 / Schedule IN-DONATE                 Schedule 5: Credits                                          Enclosure 
05     Form IT-40, State Form 53998                                                                          Sequence No. 04
       (R14 / 9-23)                                                                           2023
06
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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11                                                                                                           Round all entries
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13 1. Indiana state tax withheld: See instructions ___________________________________________            1  99999999999.00
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15 2. Indiana county tax withheld: See instructions  _________________________________________            2  99999999999.00
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17 3. Pass Through Entity Tax Credit  ____________________________________________________                3  99999999999.00
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19 4. Estimated tax paid for 2023: include any extension payment made with Form IT-9  ____________        4  99999999999.00
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21 5. Unified tax credit for the elderly ____________________________________________________             5  99999999999.00
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23 6. Earned income credit: enclose Schedule IN-EIC and enter amount from line A-3  _____________         6  99999999999.00
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25 7. Lake County residential income tax credit ____________________________________________              7  99999999999.00
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27 8. Economic development for a growing economy credit. Enter amount from Schedule IN-EDGE,  
28 line 19 (enclose schedule) ________________________________________________________                    8  99999999999.00
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30 9. Economic development for a growing economy retention credit. Enter amount from  
31 Schedule IN-EDGE-R, line 19 (enclose schedule) ______________________________________                  9  99999999999.00
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33 10. Headquarters relocation credit (refundable portion - see instructions)  ______________________     10 99999999999.00
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35 11. Adoption Credit  ________________________________________________________________                  11 99999999999.00
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37 12. Reserved for future use __________________________________________________________                 12                  .00
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39 13. Add lines 1 through 12. Enter total here and on Form IT-40, line 12 _____________Total Credits     13                                    99999999999.00
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47                                                     Schedule IN-DONATE
48                         Important: The amount on line 2 cannot exceed the amount on Form IT-40, line 16.
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50 1. Donations: List fund name, 3-digit code and amount to be donated (see instructions)
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52     a.  Enter fund name     XXXXXXXXXXXXXXXXXXXXXXXXXX code no.                       999          1a     99999999999.00
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54     b.  Enter fund name     XXXXXXXXXXXXXXXXXXXXXXXXXX code no.                       999          1b     99999999999.00
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56     c.  Enter fund name     XXXXXXXXXXXXXXXXXXXXXXXXXX code no.                       999          1c     99999999999.00 
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58 2. Add lines 1a through 1c. Enter total here and on Form IT-40, line 17  Total Donations           2      99999999999.00
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62                                         *23123111694*
63                                                          23123111694
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