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04    Schedule H                   Schedule H Section 1: Residency Information                       Enclosure                                      
05    Form IT-40PNR                 (Complete Section 2: Additional Information on back)         Sequence No. 07
      State Form 54035
06    (R14 / 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: Residency    List all state(s) and dates of your (and your spouse’s, if filing jointly) residency during 2023. Enter 2-letter 
11                          state name (e.g. “IL” for Illinois) or the letters “OC” if you were a resident of a foreign country (see instructions).
               Information
12
13  Example
14    State of     Date From             Date To               Did you file a tax return with the state/country? 
15    Residence    (MM/DD)               (MM/DD)               Place “X” in appropriate box.
16
17    IL              01  01       2023  06      01  2023      Yes X                     No
18
19
20    IN              06  02       2023  12      31  2023      Yes X                     No
21
22
23 Your information
24         (a)        (b)                   (c)
25    State of     Date From             Date To               Did you file a tax return with the state/country? 
26    Residence    (MM/DD)               (MM/DD)               Place “X” in appropriate box.
27
28 1A XX           99    99        2023  99  99      2023      Yes X                      No X
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30
31 1B XX           99    99        2023  99  99      2023      Yes X                      No X
32
33
34 1C XX           99    99        2023  99  99      2023      Yes X                      No X
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37 1D XX           99    99        2023  99  99      2023      Yes X                      No X
38
39
40 Spouse’s information if married filing jointly
41    (a)             (b)                   (c)
42    State of     Date From             Date To               Did you file a tax return with the state/country? 
43    Residence    (MM/DD)               (MM/DD)               Place “X” in appropriate box.
44
45 2A XX           99    99        2023  99  99      2023      Yes X                      No X
46
47
48 2B XX           99    99        2023  99  99      2023      Yes X                      No X
49
50
51 2C XX           99    99        2023  99  99      2023      Yes X                      No X
52
53
54 2D XX           99    99        2023  99  99      2023      Yes X                      No X
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58                                                                                           Turn over to complete Section 2 
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04       Schedule H                                 Schedule H Section 2:                                                        Enclosure         
         Form IT-40PNR                                                                                           Sequence No. 07A
05                                               Additional Required Information                     2023                       Page 2 of 2
06
07
08 Section 2: Additional Information
09
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. Extension of time to file
14   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
15
16   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
17
18 3. Farm/Fishing income
19 Place “X” in box if at least two-thirds of your gross income was made from farming or fishing.
20 Important: If you placed an “X” in the box, you MUST attach Schedule IT-2210.                 X
21
22 4. Schedule IN-40PA filers. If you are eligible to file federal Form 8857, Request for Innocent Spouse Relief, and are completing 
23 Indiana Schedule IN-40PA, enclose Schedule IN-40PA and check the box.                                                                    X
24
25 5. Date of death
26 If any individual listed at the top of the IT-40PNR died during 2023, enter date of death (MM/DD).
27
28         Taxpayer’s date of death 99           99 2023            Spouse’s date of death  99       99 2023
29
30
31
32 Authorization: Sign Form IT-40PNR after reading the following statement.
33 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-
34 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 
35 taxes due under this return. Also, my request for direct deposit of my refund includes my authorization to the Indiana Department of 
   Revenue (DOR) to furnish my financial institution with my routing number, account number, account type and Social Security number to 
36
   ensure my refund is properly deposited. I grant permission to DOR to contact the Social Security Administration to confirm that the
37 Social Security number(s) used on this return is correct.
38
39 6. Your daytime                                          Your email
40   telephone number    999999999999999                    address              XXXXXXXXXXXXXXXXXXXXXX
41
42
   I authorize the Department to discuss my return with my personal   Paid Preparer: Firm’s Name (or yours if self-employed)
43 representative.
44
45   Yes X  No X   If yes, complete the information below.            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
46
47 Personal Representative’s Name (please print)                       X      IN-OPT on file with paid preparer if not filing electronically
48
49 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                PTIN                  999999999
50 Telephone
51 number          9999999999                                         Address    XXXXXXXXXXXXXXXXXXXXXXXXXXXXX
52
53 Address XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                             City       XXXXXXXXXXXXXXXXXXXXXX
54
55 City           XXXXXXXXXXXXXXXXXXXXXX                              State                 XX          ZIP Code 999999999
56                                                                    Preparer’s
57 State          XX             ZIP Code        999999999            signature _______________________________________________
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