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04 Schedule IN-H                                    Indiana Department of Revenue                                          Enclosure 
   State Form 48684 
05 (R18 / 9-24)                        Indiana Household Employment Taxes                                     Sequence No. 12
                                                                                                    2024
06                                       Enclose with Form IT-40 or Form IT-40PNR.
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                                                                                          Federal Employer Identification Number
16
17 A. Did you file federal Schedule H for the tax year shown above?                          99       9999999
18
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
32                      Complete Part 2 (on page 2) first. Carry those totals to the Part 1 Summary below.
33
34
35 Part 1 – Summary of Household Employment Taxes
36
37 1.  Enter the total State Tax withheld from Part II, line 2 ____________________________________ 1     99999999999.00
38
39 2.  Enter the total County Tax withheld from Part II, line 3  __________________________________ 2     99999999999.00
40
41 3.  Add lines 1 and 2. Enter the total here  ______________________________________________      3     99999999999.00 
42    Enter this amount on your Indiana individual income tax return on the following lines:
43    • Form IT-40 Schedule 4, line 2,
44    • Form IT-40PNR Schedule E, line 2.
45
46
47
48 Under penalties of perjury, I declare that I have examined this schedule, including accompanying statements and W-2 forms, and to the 
49 best of my knowledge and belief it is true, correct and complete.
50
51
52
53 Employer's signature                                             Daytime telephone number              Date
54
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56
57
58
59
60
61
62                                     *24100000000*
63                                                  24100000000
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04 Part 2 – State and County Tax Withholding
05
06 Enter below the employee's name and Social Security number         Line 4. Enter the 2-digit county code from Indiana Departmental 
07 as it appears on his/her W-2 form. Attach additional pages if      Notice #1 for which the line 3 county tax was withheld.
08 withholding for more than three household employees.
09                                                                    Summary:
10 Line 1. Enter the amount on which you are withholding federal      • Add all line 2 amounts and enter on Part I, line 1. 
11 income tax (also enter on W-2 boxes 16 and 18.)                    • Add all line 3 amounts and enter on Part I, line 2.
12
13 Line 2. Enter the amount of Indiana state tax withheld (also enter Note. For detailed information on how to calculate state and 
14 on W-2 box 17. Also, enter "IN" on W-2 box 15.)                    county withholding amounts and to get the county code numbers, 
15                                                                    see Form WH-4 at forms.in.gov/Download.aspx?id=2702 and 
16 Line 3. Enter the amount of county tax withheld (also enter on     Departmental Notice #1 at https://www.in.gov/dor/files/dn01.pdf.
17 W-2 box 19).
18
19 Employee Name (First, Middle Initial, 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
33
34 Employee Name (First, Middle Initial, 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
48
49 Employee Name (First, Middle Initial, 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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