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04       Schedule IN-DEP     Schedule IN-DEP: Dependent Information and Additional                                         Enclosure 
         Form IT-40/IT-40PNR                                                                                    Sequence No. 03A/04A
05       State Form 54815                   Dependent Child Information
06       (R12 / 9-23)
                                                                                                                           2023
07
08  Name(s) shown on Form IT-40/IT-40PNR                                                      Your Social Security Number
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10 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                            999 99                 9999
11       Dependent’s First Name                 Dependent’s Last Name
12  
13   1A. XXXXXXXXXXXXXXXXXXXX               1B. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
14       Dependent’s Social Security Number     Dependent’s Date of Birth (mm dd yyyy)
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16   1C. 999         99         9999        1D. 99 99         9999
17   1E.  Place “X” in box 1E if claiming dependent as an additional dependent child exemption _________________ 1E      X
18
19   1F.  Place “X” in box 1F if dependent child claimed for the first time (see instructions) _____________________ 1F  X
20  
21       Dependent’s First Name                 Dependent’s Last Name
22  
23   2A. XXXXXXXXXXXXXXXXXXXX               2B. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
24       Dependent’s Social Security Number     Dependent’s Date of Birth (mm dd yyyy)
25  
26   2C. 999              99    9999        2D. 99 99         9999
27   2E.  Place “X” in box 2E if claiming dependent as an additional dependent child exemption _________________ 2E      X
28
29   2F.  Place “X” in box 2F if dependent child claimed for the first time (see instructions) _____________________ 2F  X
30  
31       Dependent’s First Name                 Dependent’s Last Name
32  
33   3A. XXXXXXXXXXXXXXXXXXXX               3B. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
34       Dependent’s Social Security Number     Dependent’s Date of Birth (mm dd yyyy)
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36   3C. 999         99         9999        3D. 99 99         9999
37   3E.  Place “X” in box 3E if claiming dependent as an additional dependent child exemption _________________ 3E      X
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39   3F.  Place “X” in box 3F if dependent child claimed for the first time (see instructions) _____________________ 3F  X
40  
41       Dependent’s First Name                 Dependent’s Last Name
42  
43   4A. XXXXXXXXXXXXXXXXXXXX               4B. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
44       Dependent’s Social Security Number     Dependent’s Date of Birth (mm dd yyyy)
45
46   4C. 999         99         9999        4D. 99 99         9999
47   4E.  Place “X” in box 4E if claiming dependent as an additional dependent child exemption _________________ 4E      X
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49   4F.  Place “X” in box 4F if dependent child claimed for the first time (see instructions) _____________________ 4F  X
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51   5. Dependent Exemptions. Add the number of dependents listed above (see instructions). Enter the total 
52  here and in the box on line 2 of Schedule 3 (if filing Form IT-40) or Schedule D (if filing Form IT-40PNR) _____ Box 5  99
53
54   6. Additional Dependent Exemptions. Add the total number of boxes with Xs from lines 1E,1F, 2E, 2F, 3E, 3F,  
55  4E and 4F if applicable. Enter the total here and in the box on line 3 of Schedule 3 (if filing Form IT-40) 
56  or Schedule D (if filing Form IT-40PNR) ________________________________________________________                 Box 6  99
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62                                         *25623111694*
63                                                 25623111694
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