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04       Schedule 7                   Schedule 7: Additional Required Information                                                Enclosure 
05       Form IT-40, State Form 54000                                                                       Sequence No. 06
         (R14 / 9-23)                                                                              2023
06
07  Name(s) shown on Form IT-40                                                             Your Social Security Number
08
09 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                          999       99    9999
10 1. Federal filing information
11 Are you filing a federal income tax return for 2023? Place “X” in appropriate box. Yes X No X
12                                                                                  
13 2. Out-of-state income: Complete if you and/or your spouse (if filing a joint return) received any salary, wage, tip and/or commission 
14 income from Illinois, Kentucky, Michigan, Ohio, Pennsylvania or Wisconsin. Enter two-digit code number from the back of Schedule CT-40 
15 for state where you and/or your spouse worked.
16 State where you worked             Your income                   State where spouse worked            Spouse’s income
17
18         XX                   $  999999999             .00                    XX                    $  999999999               .00
19 3. Extension of time to file
20   a. Place “X” in box if you have filed a federal extension of time to file, Form 4868, or made an online extension payment. X
21  
22   b. Place “X” in box if you have filed an Indiana extension of time to file, Form IT-9, or made an Indiana extension payment online. X
23
24 4. Farm/Fishing income
25 Place “X” in box if at least two-thirds of your gross income was made from farming or fishing. X
26 Important: If you placed an “X” in the box, you MUST attach Schedule IT-2210.
27 5. Schedule IN-40PA filers. If you are eligible to file federal Form 8857, Request for Innocent Spouse Relief, and are completing
28 Indiana Schedule IN-40PA, enclose Schedule IN-40PA and check the box.                                                                 X
29
30 6. Date of death
31 If any individual listed at the top of the IT-40 died during 2023, enter date of death (MM/DD).
32  
33       Taxpayer’s date of death     99   99            2023 Spouse’s date of death        99     99 2023
34 Authorization: Sign Form IT-40 after reading the following statement.
35 Under penalty of perjury, I have examined this return and all attachments and to the best of my knowledge and belief, it is true, com-
36 plete and correct. I understand that if this is a joint return, any refund will be made payable to us jointly and each of us is liable for all 
37 taxes due under this return. Also, my request for direct deposit of my refund includes my authorization to the Indiana Department of 
38 Revenue (DOR) to furnish my financial institution with my routing number, account number, account type and Social Security number to 
39 ensure my refund is properly deposited. I grant permission to DOR to contact the Social Security Administration to confirm that the
40 Social Security number(s) used on this return is correct.
41
42 7. Your daytime                                              Your
43   telephone number                                           email address 
                           999999999999999                                                XXXXXXXXXXXXXXXXXXXXXX
44
45 I authorize the Department to discuss my return with my          Paid Preparer: Firm’s Name (or yours if self-employed)
   personal representative.
46
47   Yes X  No X      If yes, complete the information below.       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
48
49 Personal Representative’s Name (please print)                     X        IN-OPT on file with paid preparer if not filing electronically
50
51 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                              PTIN                    999999999
52 Telephone
53 number             9999999999                                    Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXX
54
55 Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                           City                  XXXXXXXXXXXXXXXXXXXXXX
56
57 City        XXXXXXXXXXXXXXXXXXXXXX                               State                   XX     ZIP Code 999999999
58                                                                  Preparer’s
59 State         XX              ZIP Code  999999999                signature _________________________________________
60
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62                                        *23323111694*
63                                                              23323111694
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