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04 Schedule IN-H         Indiana Household Employment Taxes                                                  Enclosure 
   State Form 48684
05 (R17 / 9-23)                        Attach to Form IT-40 or Form IT-40PNR.                            Sequence No. 12
06                                                                                         2023
07
08              This schedule should be filed by an individual who:
09                • withholds state and county (if applicable) tax on household employees, AND
10                • pays those withholding taxes with the filing of his/her individual income tax return.
11
12  Name of employer (as shown on individual income tax return)                Employer Social Security Number
13
14 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                               999       99            9999
15
16                                                                             Federal Employer Identification Number
17 A  Did you file federal Schedule H for the tax year shown above?
18                                                                               99           9999999
19   X          Yes.  Go to question B.
20
21   X          No. Stop. Do not file this schedule.
22
23 B  Did you withhold state and/or county income tax for any household employee?
24
25   X          Yes.  Complete Part II on the back of this schedule.
26
27   X          No. Stop. Do not file this schedule.
28
29 C  Make sure you enclose the state copy of your employee's W-2 forms.
30
31
       Complete Part II (on page 2) first. Carry those totals to the Part I Summary below.
32
33
34 Part 1:               Summary of Household Employment Taxes
35
36 1.  Enter the total State Tax withheld from Part II, line 2  __________________________ 1  99999999999.00
37
38 2.  Enter the total County Tax withheld from Part II, line 3   ________________________ 2  99999999999.00
39
40 3.  Add lines 1 and 2. Enter the total here  _____________________________________      3  99999999999.00
41   Enter this amount on your Indiana individual income tax return on the following lines:
42     •  Form IT-40 Schedule 4, line 2,
43     •  Form IT-40PNR Schedule E, line 2.
44
45
46 Under penalties of perjury, I declare that I have examined this schedule, including accompanying statements and W-2 forms, 
47 and to the best of my knowledge and belief it is true, correct and complete.
48
49
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   ___________________________________                ______________________                   ___________
51 Employer's signature                             Daytime telephone number                  Date
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54
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58
59
60
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62                                     *24100000000*
63                                                  24100000000
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04  Part II: State and County Tax Withholding                     Line 4 - Enter the 2-digit county code from Indiana 
05                                                                Departmental Notice #1 for which the line 3 county tax was 
06 Enter below the employee's name and Social Security number  withheld.
07 as it appears on his/her W-2 form. Attach additional pages if 
08 withholding for more than three household employees.           Summary -
09                                                                ♦ Add all line 2 amounts and enter on Part I, line 1. 
10 Line 1 - Enter the amount on which you are withholding federal ♦ Add all line 3 amounts and enter on Part I, line 2.
11 income tax (also enter on W-2 boxes 16 and 18.)
12                                                                Note: Get Form WH-4 and Departmental Notice #1 for detailed 
13 Line 2 - Enter the amount of Indiana state tax withheld (also 
                                                                  information on how to calculate state and county withholding 
14 enter on W-2 box 17. Also, enter "IN" on W-2 box 15.) 
                                                                  amounts and to get the county code numbers. This information 
15                                                                is available on our web site at https://forms.in.gov/Download.
16 Line 3 - Enter the amount of county tax withheld (also enter 
                                                                  aspx?id=2702 and www.in.gov/dor/files/reference/dn01.pdf
17 on W-2 box 19).
18
19 Employee Name (First, M.I., Last)                                             Employee Social Security Number
20
21 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                   999     99          9999
22  
23
24 Income  __________________________________________________________________________        1      99999999999.00
25
26 State Tax Withheld  ________________________________________________________________    2        99999999999.00
27
28 County Tax Withheld  ______________________________________________________________       3      99999999999.00
29
30 County Code Number (2-digit) _________________________________________________________      4    99
31
32
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34 Employee Name (First, M.I., Last)                                             Employee Social Security Number
35
36 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                   999     99          9999
37
38
39 Income  __________________________________________________________________________        1      99999999999.00
40
41 State Tax Withheld  ________________________________________________________________    2        99999999999.00
42
43 County Tax Withheld  ______________________________________________________________       3      99999999999.00
44
45 County Code Number (2-digit) _________________________________________________________      4    99
46
47
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49 Employee Name (First, M.I., Last)                                             Employee Social Security Number
50
51  XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                  999     99          9999
52
53
54 Income  __________________________________________________________________________        1      99999999999.00
55
56 State Tax Withheld  ________________________________________________________________    2        99999999999.00
57
58 County Tax Withheld  ______________________________________________________________       3      99999999999.00
59
60 County Code Number (2-digit) _________________________________________________________      4    99
61
62                                   *24100000000*
63                                                       24100000000
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