Schedule IN-DEP-A                  Schedule IN-DEP-A:                                                                               Enclosure 
      Form IT-40/IT-40PNR                                                                           Sequence No. 03B/04B
      State Form 53111                Adopted Dependent Information
      (R2/ 9-23)
                                                                                                                                          2023
 Name(s) shown on Form IT-40/IT-40PNR                                                  Your Social Security Number

      Adopted Dependent’s First Name     Adopted Dependent’s Last Name

  1A.                                 1B.
      Adopted Dependent’s Social Security Number  Adopted Dependent’s Date of Birth (mm dd yyyy)

  1C.                                 1D.
  1E.  Place “X” in box if the first listed taxpayer is an adoptive parent of the child __________________________ 1E
  1F.  Place “X” in box if the spouse is an adoptive parent of the child ___________________________________ 1F

      Adopted Dependent’s First Name     Adopted Dependent’s Last Name

  2A.                                 2B.
      Adopted Dependent’s Social Security Number  Adopted Dependent’s Date of Birth (mm dd yyyy)

  2C.                                 2D.
  2E.  Place “X” in box if the first listed taxpayer is an adoptive parent of the child __________________________ 2E
  2F.  Place “X” in box if the spouse is an adoptive parent of the child ___________________________________ 2F

      Adopted Dependent’s First Name     Adopted Dependent’s Last Name

  3A.                                 3B.
      Adopted Dependent’s Social Security Number  Adopted Dependent’s Date of Birth (mm dd yyyy)

  3C.                                 3D.
  3E.  Place “X” in box if the first listed taxpayer is an adoptive parent of the child __________________________ 3E
  3F.  Place “X” in box if the spouse is an adoptive parent of the child ___________________________________ 3F

      Adopted Dependent’s First Name     Adopted Dependent’s Last Name

  4A.                                 4B.
      Adopted Dependent’s Social Security Number  Adopted Dependent’s Date of Birth (mm dd yyyy)

  4C.                                 4D.
  4E.  Place “X” in box if the first listed taxpayer is an adoptive parent of the child __________________________ 4E
  4F.  Place “X” in box if the spouse is an adoptive parent of the child ___________________________________ 4F

      Adopted Dependent’s First Name     Adopted Dependent’s Last Name

  5A.                                 5B.
      Adopted Dependent’s Social Security Number  Adopted Dependent’s Date of Birth (mm dd yyyy)

  5C.                                 5D.
  5E.  Place “X” in box if the first listed taxpayer is an adoptive parent of the child __________________________ 5E
  5F.  Place “X” in box if the spouse is an adoptive parent of the child ___________________________________ 5F

 6.  Add the number of adopted dependents list above (see instructions). Enter the total here and  
      the box on line 6 of Schedule 3 (if filing Form IT-40) or Schedule D (if filing form IT-40PNR) ..............................  Box 6

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