01
0000000000111111111122222222223333333333444444444455555555556666666666777777777788888
1234567890123456789012345678901234567890123456789012345678901234567890123456789012345
04       Schedule IN-DEP-A                   Schedule IN-DEP-A:                                                                               Enclosure 
         Form IT-40/IT-40PNR                                                                              Sequence No. 03B/04B
05       State Form 53111                Adopted Dependent Information
06       (R / 9-23)
                                                                                                                                         2023
07
08  Name(s) shown on Form IT-40/IT-40PNR                                                  Your Social Security Number
09
10 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                        999          99 9999
11       Adopted Dependent’s First Name      Adopted Dependent’s Last Name

12   1A. XXXXXXXXXXXXXXXXXXXX            1B. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
13
14       Adopted Dependent’s Social Security Number  Adopted Dependent’s Date of Birth (mm dd yyyy)

15   1C. 999       99        9999        1D. 99 99                         9999
16
17   1E.  Place “X” in box if the first listed taxpayer is an adoptive parent of the child __________________________ 1E                X
18   1F.  Place “X” in box if the spouse is an adoptive parent of the child ___________________________________ 1F                      X
19
20       Adopted Dependent’s First Name      Adopted Dependent’s Last Name
21
22   2A. XXXXXXXXXXXXXXXXXXXX            2B. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
23       Adopted Dependent’s Social Security Number  Adopted Dependent’s Date of Birth (mm dd yyyy)
24
25   2C. 999       99        9999        2D. 99 99                         9999
26   2E.  Place “X” in box if the first listed taxpayer is an adoptive parent of the child __________________________ 2E                X
27
28   2F.  Place “X” in box if the spouse is an adoptive parent of the child ___________________________________ 2F                      X
29
30       Adopted Dependent’s First Name      Adopted Dependent’s Last Name

31   3A. XXXXXXXXXXXXXXXXXXXX            3B. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
32
33       Adopted Dependent’s Social Security Number  Adopted Dependent’s Date of Birth (mm dd yyyy)

34   3C. 999       99        9999        3D. 99 99                         9999
35
36   3E.  Place “X” in box if the first listed taxpayer is an adoptive parent of the child __________________________ 3E                X
37   3F.  Place “X” in box if the spouse is an adoptive parent of the child ___________________________________ 3F                      X
38
39       Adopted Dependent’s First Name      Adopted Dependent’s Last Name
40
41   4A. XXXXXXXXXXXXXXXXXXXX            4B. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
42       Adopted Dependent’s Social Security Number  Adopted Dependent’s Date of Birth (mm dd yyyy)
43
44   4C. 999       99        9999        4D. 99 99                         9999
45   4E.  Place “X” in box if the first listed taxpayer is an adoptive parent of the child __________________________ 4E                X
46
47   4F.  Place “X” in box if the spouse is an adoptive parent of the child ___________________________________ 4F                      X
48
49       Adopted Dependent’s First Name      Adopted Dependent’s Last Name

50   5A. XXXXXXXXXXXXXXXXXXXX            5B. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
51
52       Adopted Dependent’s Social Security Number  Adopted Dependent’s Date of Birth (mm dd yyyy)

53   5C. 999       99        9999        5D. 99 99                         9999
54
55   5E.  Place “X” in box if the first listed taxpayer is an adoptive parent of the child __________________________ 5E                X

56   5F.  Place “X” in box if the spouse is an adoptive parent of the child ___________________________________ 5F                      X
57
58  6.  Add the number of adopted dependents list above (see instructions). Enter the total here and  
59       the box on line 6 of Schedule 3 (if filing Form IT-40) or Schedule D (if filing form IT-40PNR) ..............................  Box 6 99
60
61
62                                       *26323111694*
63                                              26323111694
64
65
66