Schedule H                                Indiana Department of Revenue                                                  Enclosure       
    Form IT-40PNR                                                                                                            Sequence No. 07
    State Form 54035      Schedule H, Section 1: Residency Information                                      2024             Page 1 of 2
    (R15 / 9-24)                    (Complete Section 2: Additional Information on back.)

Name(s) shown on IT-40PNR                                                   Your Social Security Number

Section 1: Residency Information
List all state(s) and dates of your (and your spouse’s, if filing jointly) residency during 2024. Enter 2-letter state name  
(e.g. “IL” for Illinois) or the letters “OC” if you were a resident of a foreign country (see instructions).

Example
    A                     B                      C                                                            D
    State of              Date From              Date To                    Did you file a tax return with the state/country? 
Residence                 (MM/DD)                (MM/DD)                                 Place “X” in appropriate box.

    IL               01   01      2024        06 01         2024                         Yes                X  No

    IN               06   02      2024        12 31         2024                         Yes                X  No

Your Information
    A                     B                      C                                                            D
    State of              Date From              Date To                    Did you file a tax return with the state/country? 
Residence                 (MM/DD)                (MM/DD)                                 Place “X” in appropriate box.

1a.                               2024                      2024                         Yes                   No

1b.                               2024                      2024                         Yes                   No

1c.                               2024                      2024                         Yes                   No

1d.                               2024                      2024                         Yes                   No

Spouse’s Information if Married Filing Jointly
    A                     B                      C                                                            D
    State of              Date From              Date To                    Did you file a tax return with the state/country? 
Residence                 (MM/DD)                (MM/DD)                                 Place “X” in appropriate box.

2a.                               2024                      2024                         Yes                   No

2b.                               2024                      2024                         Yes                   No

2c.                               2024                      2024                         Yes                   No

2d.                               2024                      2024                         Yes                   No

                                                                                                            Turn over to complete Section 2 

                                    *24024111694*
                                                 24024111694

      Schedule H                              Indiana Department of Revenue                                                     Enclosure      
      Form IT-40PNR                                                                                       Sequence No. 07A
      (continued)                             Schedule H, Section 2:                              2024                          Page 2 of 2
                                      Additional Required Information

Section 2: Additional Information

1. Federal filing information
Are you filing a federal income tax return for 2024? Place “X” in appropriate box. Yes         No 

2. Extension of time to file
   a.  Place “X” in box if you have filed a federal extension of time to file, Form 4868, or made an online extension payment.  

   b.  Place “X” in box if you have filed an Indiana extension of time to file, Form IT-9, or made an Indiana extension payment online. 

3.  Farm/Fishing income
Place “X” in box if at least two-thirds of your gross income was made from farming or fishing. 
Important: If you placed an “X” in the box, you MUST attach Schedule IT-2210.

4. Schedule IN-40PA filers.
If you are eligible to file federal Form 8857, Request for Innocent Spouse Relief, and are completing Indiana Schedule IN-40PA, 
enclose Schedule IN-40PA and check the box. 

5.  Date of death
If any individual listed at the top of the IT-40PNR died during 2024, enter date of death (MM/DD).

      Taxpayer’s date of death                2024             Spouse’s date of death             2024

6. Enter the number of days you worked in Indiana during this calendar year (see instructions).

   You                  Spouse 

Authorization – Sign Form IT-40PNR after reading the following statement.
Under penalty of perjury, I have examined this return and all attachments and to the best of my knowledge and belief, it is true, 
complete and correct. I understand that if this is a joint return, any refund will be made payable to us jointly and each of us is liable for 
all taxes due under this return. Also, my request for direct deposit of my refund includes my authorization to the Indiana Department of 
Revenue (DOR) to furnish my financial institution with my routing number, account number, account type and Social Security number to 
ensure my refund is properly deposited. I grant permission to DOR to contact the Social Security Administration to confirm that the
Social Security number(s) used on this return is correct.
7.  Your daytime                                               Your email 
   telephone number                                            address

I authorize the Department to discuss my return with my        Paid Preparer: Firm’s Name (or yours if self-employed)
personal representative.
Yes       No      If yes, complete the information below.

Personal Representative’s Name (please print)                             IN-OPT on file with paid preparer if not filing electronically

                                                               PTIN
Telephone 
number                                                         Address

Address                                                        City

City                                                           State                              ZIP Code
                                                               Preparer’s 
State                        ZIP Code                          signature

                                      *24024121694*
                                                               24024121694