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04       Schedule IN-DEP-A              Indiana Department of Revenue                                                        Enclosure 
         Form IT-40/IT-40PNR                                                                             Sequence No. 03B/04B
05       State Form 53111               Adopted Dependent Information                                2024
06       (R3 / 9-24)
07 Name(s) shown on Form IT-40/IT-40PNR                                                Your Social Security Number
08
09 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                     999           99                9999
10       Adopted Dependent’s First Name Adopted Dependent’s Last Name
11
12 1A.   XXXXXXXXXXXXXXXXXXXX           1B.   XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
13       Adopted Dependent’s Social Security Number Adopted Dependent’s Date of Birth (mm dd yyyy)
14
15 1C.   999        99       9999       1D.   99 99                     9999
16 1E. Place “X” in box if the first listed taxpayer is an adoptive parent of the child ____________________________  1E X
17
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
   2A.                                  2B.   
22       XXXXXXXXXXXXXXXXXXXX           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
23       Adopted Dependent’s Social Security Number Adopted Dependent’s Date of Birth (mm dd yyyy)
24
   2C.                                  2D.   
25       999        99       9999             99 99                     9999
   2E. Place “X” in box if the first listed taxpayer is an adoptive parent of the child ____________________________  2E
26                                                                                                                       X
27
   2F. Place “X” in box if the spouse is an adoptive parent of the child _____________________________________   2F
28                                                                                                                       X
29       Adopted Dependent’s First Name Adopted Dependent’s Last Name
30
31 3A.   XXXXXXXXXXXXXXXXXXXX           3B.   XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
32       Adopted Dependent’s Social Security Number Adopted Dependent’s Date of Birth (mm dd yyyy)
33
34 3C.   999        99       9999       3D.   99 99                     9999
35 3E. Place “X” in box if the first listed taxpayer is an adoptive parent of the child ____________________________  3E X
36
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
   4A.                                  4B.   
41       XXXXXXXXXXXXXXXXXXXX           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
42       Adopted Dependent’s Social Security Number Adopted Dependent’s Date of Birth (mm dd yyyy)
43
   4C.                                  4D.   
44       999        99       9999             99 99                     9999
   4E. Place “X” in box if the first listed taxpayer is an adoptive parent of the child ____________________________  4E
45                                                                                                                       X
46
   4F. Place “X” in box if the spouse is an adoptive parent of the child _____________________________________   4F
47                                                                                                                       X
48       Adopted Dependent’s First Name Adopted Dependent’s Last Name
49
50 5A.   XXXXXXXXXXXXXXXXXXXX           5B.   XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
51       Adopted Dependent’s Social Security Number Adopted Dependent’s Date of Birth (mm dd yyyy)
52
53 5C.   999        99       9999       5D.   99 99                     9999
54 5E. Place “X” in box if the first listed taxpayer is an adoptive parent of the child ____________________________  5E X
55
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
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62                                      *26324111694*
63                                               26324111694
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