Form It-40 - Indiana Full-Year Resident Individual Income Tax Return - 2001 Page 4

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Schedule IN-EIC

Attachment

Schedule IN-EIC: Indiana’s Earned Income Credit

Form IT-40/IT-40PNR

Sequence No. 05

Attach only if claiming this credit

State Form 49469 (R / 8-01)

Enter your first name, middle initial and last name and spouses full name if filing a joint return

Your Social

Security Number

Section A: Figure your Total Federal Income

Enter the “total income” before federal deductions (e.g. IRA deduction, student loan deduction, etc.) from

your federal Form 1040, Form 1040A, or Form 1040EZ (if less than zero, enter zero) ....................................

A1 $ ____________

Is the line A1 amount less than $12,000?

Yes, Continue to Section B.

No, STOP. You do not get this credit.

Section B: Qualifying Child (Read the instructions in the booklet to explain the terms used below)

First

Enter each Child’s Name here

Last

(Please print clearly or type)

Check only one box in each section for each child listed.

Your child

Adopted child

Grandchild

B-1

Stepchild

Foster child, (not related)

Foster child, (related)

Under age 18

Age 18

B-2

Age 19 - 24 and a full-time student

Age 19 or older and totally disabled

Child lived with you at least 1/2 of the

year (If not, see below)

(if foster child,

B-3

must have lived with you entire year)

Child was born or died in 2001,

and lived with you while alive in 2001.

You must have a qualifying child to continue to Section C. A child qualifies only if a box is checked in Sections B-1, B-2 and B-3.

If you do not have a qualifying child, STOP. You do not get this credit.

(Attach a separate sheet of paper to list additional children.)

Section C: Figure your Earned Income

Before you begin:

If you were a household employee and received a W-2 for less than $1,300 in 2001 or were a minister or

member of a religious order, see Special Rules in the booklet or on the back of this schedule before

completing this section. Also see Special Rules if your federal adjusted gross income includes workfare

payments or any amount paid to an inmate in a penal institution.

Enter your (and spouses if filing joint) wages, salary, tips and other compensation from federal Form 1040,

1040A, or Form 1040EZ .................................................................................................................................... C1 $ _____________

Enter any nontaxable earned income (e.g. from box 12 of your W-2 form; see instructions in the booklet) ..... C2 $ _____________

If you were self-employed, complete the worksheet on the back and enter the amount from line 4 ................. C3 $ _____________

Add lines C1, C2 and C3 and enter here (if this is a loss, STOP. You do not get this credit) ........................... C4 $ _____________

Enter amount from Section A line A1 above $ _______________ Multiply by 80% (.80) and enter here ....... C5 $ _____________

Is the amount on line C4 equal to or greater than the amount on line C5?

No, STOP. You do not get this credit.

Yes, Continue to Section D on the back to figure your credit.