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04 Schedule IN-WH3                        Schedule IN-WH3: 
   Form WH-3, State Form 53057
05 (6-22)                                 Indiana Withholding Statements
                                                                                                   2022
06
07 Employer Name(s) shown on Form WH-3                                               Federal Employer Identification Number
08
09
10
11        A                   B           C                     D                    E             F            G
12        Form Employee Identification    State                 State Tax            Local         Local Tax   Locality 
      Code          Number                Income                Withheld             Income        Withheld    Code
13
14 1
15 2
16
17 3
18 4
19
20 5
21 6
22
23 7
24 8
25
26 9
27 10
28
29 11
30 12
31
32 13
33 14
34
35 15
36 16
37
38 17
39 18
40
41 19
42 20
43
44 21
45 22
46
47 23
48 24
49
50 25
      Add lines 1 through 25 in column D. Enter total on line 1 
51 26
52    of Form WH-3.
53 27 Add lines 1 through 25 in column F. Enter total on line 2 of Form WH-3.
54
55
56
                                          Schedule IN-WH3 Reference Chart
57        Form Type             Form Code Form Type                        Form Code   Form Type       Form Code
58          W2/W2C              W         1099R                              R              1099G            U 
59             W2G              G         1099M                              M             1099NEC           N
60
61
62                                        *26222111694*
63                                                              26222111694
64
65
66

                    Instructions for Schedule IN-WH3: Indiana Withholding Statements

You must complete Schedule IN-WH3 when filing Form WH-3.            01 - ADAMS       32 - HENDRICKS  63 - PIKE
Enter information from each W-2 or 1099. 
                                                                    02 - ALLEN       33 - HENRY      64 - PORTER
Reminder: Any employer that files a combined total of more          03 - BARTHOLOMEW 34 - HOWARD     65 - POSEY
than 25 withholding statements is required to file those forms      04 - BENTON      35 - HUNTINGTON 66 - PULASKI
electronically.
                                                                    05 - BLACKFORD   36 - JACKSON    67 - PUTNAM
Column A, Form Code. Enter the appropriate form code listed on      06 - BOONE       37 - JASPER     68 - RANDOLPH
the Reference Chart.
                                                                    07 - BROWN       38 - JAY        69 - RIPLEY
Column B, Employee Identification Number. Enter the                 08 - CARROLL     39 - JEFFERSON  70 - RUSH
employee’s Social Security number or recipient’s tax identification 09 - CASS        40 - JENNINGS   71 - ST. JOSEPH
number.
                                                                    10 - CLARK       41 - JOHNSON    72 - SCOTT
Column C, State Income. Enter the amount of Indiana income.         11 - CLAY        42 - KNOX       73 - SHELBY
                                                                    12 - CLINTON     43 - KOSCIUSKO  74 - SPENCER
Column D, State Tax Withheld. Enter the amount of Indiana 
State Tax withheld.                                                 13 - CRAWFORD    44 - LAGRANGE   75 - STARKE
                                                                    14 - DAVIESS     45 - LAKE       76 - STEUBEN
Complete Columns E, F and G only if there is Indiana local          15 - DEARBORN    46 - LAPORTE    77 - SULLIVAN
withholding.
                                                                    16 - DECATUR     47 - LAWRENCE   78 - SWITZERLAND
Column E, Local Income. Enter the amount of Indiana local           17 - DEKALB      48 - MADISON    79 - TIPPECANOE
income.                                                             18 - DELAWARE    49 - MARION     80 - TIPTON
Column F, Local Tax Withheld. Enter the amount of County Tax        19 - DUBOIS      50 - MARSHALL   81 - UNION
withheld.                                                           20 - ELKHART     51 - MARTIN     82 - VANDERBURGH
                                                                    21 - FAYETTE     52 - MIAMI      83 - VERMILLION
Column G, Locality Code. Enter the appropriate Indiana 2-digit 
county code.                                                        22 - FLOYD       53 - MONROE     84 - VIGO
                                                                    23 - FOUNTAIN    54 - MONTGOMERY 85 - WABASH
Line 26. Add Column D, lines 1 through 25. Enter this total on line 24 - FRANKLIN    55 - MORGAN     86 - WARREN
1 of Form WH-3.
                                                                    25 - FULTON      56 - NEWTON     87 - WARRICK
Line 27. Add Column F, lines 1 through 25. Enter this total on line 26 - GIBSON      57 - NOBLE      88 - WASHINGTON
2 of Form WH-3.                                                     27 - GRANT       58 - OHIO       89 - WAYNE
                                                                    28 - GREENE      59 - ORANGE     90 - WELLS
                                                                    29 - HAMILTON    60 - OWEN       91 - WHITE
                                                                    30 - HANCOCK     61 - PARKE      92 - WHITLEY
                                                                    31 - HARRISON    62 - PERRY

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