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04     Schedule A                       Schedule A Section 1: Income or Loss                                      Enclosure 
       Form IT-40PNR                    (Complete Proration, Section 2 and Section 3 on back)             Sequence No.
05     State Form 48719                                                                                                         01
06     (R22 / 9-23)                                                                                  2023     Page 1 of 2

07 Name(s) shown on Form IT-40PNR                                                 Your Social Security Number
08
09 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                999                 99  9999
10
   Section 1: Income or (Loss) Enter in Column A the same income or loss you reported on your 2023 federal income tax return, Form 
11
   1040, Form 1040-SR, and Form 1040 Schedule 1 (except for line 19B and/or a net operating loss carryforward on line 20B; see 
12 instructions). Round all entries.
13                                                                       Column A                         Column B
14                                                                 Income from Federal Return         Income Taxed by Indiana 
15
16 1.  Your wages, salaries, tips, commissions, etc _____________  1A    99999999999.00               1B  99999999999.00
17
18 2.  Spouse’s wages, salaries, tips, commissions, etc  _________ 2A    99999999999.00               2B  99999999999.00
19
20 3.  Taxable interest income  _____________________________      3A    99999999999.00               3B  99999999999.00
21
22 4.  Dividend income  __________________________________         4A    99999999999.00               4B  99999999999.00
23 5.  Taxable refunds, credits, or offsets of state 
24     and local taxes from your federal return  ________________  5A    99999999999.00               5B  99999999999.00
25
26 6.  Alimony received  __________________________________        6A    99999999999.00               6B  99999999999.00 
27
28 7.  Business income or loss from federal Schedule C  ________   7A    99999999999.00               7B  99999999999.00
29 8.  Capital gain or loss from sale or exchange 
30     of property from your federal return ____________________   8A    99999999999.00               8B  99999999999.00
31
32 9.  Other gains or (losses) from Form 4797  ________________    9A    99999999999.00               9B  99999999999.00
33
34 10.  Taxable IRA distribution _____________________________  10A      99999999999.00               10B 99999999999.00
35
36 11.  Taxable pensions and annuities _______________________  11A      99999999999             .00  11B 99999999999.00
37 12.  Net rent or royalty income or loss reported on 
38     federal Schedule E  ________________________________  12A         99999999999.00               12B 99999999999.00
39
40 13.  Income or loss from partnerships  _____________________  13A     99999999999.00               13B 99999999999.00
41
42 14.  Income or loss from trusts and estates  _________________  14A   99999999999.00               14B 99999999999.00
43
44 15.  Income or loss from S corporations  ____________________  15A    99999999999.00               15B 99999999999.00
45
46 16.  Farm income or loss from federal Schedule F ____________  16A    99999999999.00               16B 99999999999.00
47
48 17.  Unemployment compensation  ________________________  17A         99999999999.00               17B 99999999999.00
49
50 18. Taxable Social Security benefits _______________________  18A     99999999999. 00              18B 99999999999.00
51 19.  Indiana apportioned income from 
52     Schedule IT-40PNRA   ___________________________________________________________  19B              99999999999.00
53
54 20.  Other income reported on your federal return  ____________  20A  99999999999.00               20B 99999999999.00
55     List source(s). (Do not include federal net operating loss in Column B. See instructions.)
56
57    XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
58
59 21.  Subtotal: add lines 1 through 20 _______________________   21A   99999999999             .00  21B 99999999999.00
60
61
62                                      *23423111694*
63                                                      23423111694
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04     Schedule A                                  Schedule A Proration;                                               Enclosure 
       Form IT-40PNR                                                                                           Sequence No. 01A
05                                       Section 2: Adjustments to Income                       2023             Page 2 of 2
06
07
08 Proration Section See instructions.
09
10
11 21C. Note: Nonresident military personnel see special instructions and complete worksheet ________  21C     99999999999.00
12
13 21D. For all other individuals, divide the amount on line 21B by the amount on line 21A (see instructions 
14     if either line 21A and/or 21B are less than zero). Please round your answer to a decimal followed  
15     by three numbers. Example: $3,100 ÷$8,000 = .3875, which rounds to .388 (do not enter a  
16     number greater than 1.00). Enter result here and on Schedule D, line 8 _________________________   21D  9.999
17
18
19 Section 2: Adjustments to Income Note: Enter in Column A only those deductions claimed on your 2023 federal income tax return,  
20           Form 1040, Form 1040-SR, and Form 1040, Schedule 1, Part II. Round all entries.
21                                                                        Column A                             Column B
22                                                                       Federal Adjustments                   Indiana Adjustments
23
24 22. Educator expenses (see instructions) _________________   22A      99999999999   .00                22B  99999999999.00
25 23. Certain business expenses of reservists, 
26  performing artists, etc  _____________________________   23A         99999999999   .00                23B  99999999999.00
27
28 24. Health savings account deduction ____________________   24A       99999999999   .00                24B  99999999999.00
29
30 25. Moving expenses (see instructions) ___________________   25A      99999999999   .00                25B  99999999999.00
31
32 26. Deductible part of self-employment tax ________________   26A     99999999999   .00                26B  99999999999.00
33
34 27. Self-employed, SEP, SIMPLE, and qualified plans _______   27A     99999999999   .00                27B  99999999999.00
35
36 28. Self-employed health insurance deduction _____________   28A      99999999999   .00                28B  99999999999.00
37
38 29. Penalty on early withdrawal of savings ________________   29A     99999999999   .00                29B  99999999999.00
39
40 30. Alimony paid  ____________________________________   30A          99999999999   .00                30B  99999999999.00
41
42 31. IRA deduction ____________________________________   31A          99999999999   .00                31B  99999999999.00
43
44 32. Student loan interest deduction (see instructions) ________   32A 99999999999   .00                32B  99999999999.00
45
46 33. Reserved for future use ____________________________   33A        99999999999.00                   33B  99999999999.00
47
48 34. Other (see instructions) XXXXXXXXXXXXXXXXXXX  34A                 99999999999   .00                34B  99999999999.00
49
50 35. Add lines 22 through 34 ____________________________     35A      99999999999   .00                35B  99999999999.00
51
52
53 Section 3: Totals
54
55 36. Subtract line 35 from line 21 of Section 1. Carry  
56  amount from line 36B to Form IT-40PNR, line 1  _________    36A      99999999999   .00                36B  99999999999.00
57
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62                                        *23423121694*
63                                                        23423121694
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