Form It-541 - Fiduciary Income Tax Return - 2016 Page 3

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IT-541 (1/17)

LDR Account Number:

Computation of Income

30 Amount owed – If Line 19 is greater than Line 26, subtract Line 26 from Line 19.

31 Interest – From the Interest Calculation Worksheet, page 16, Line 5.

Delinquent filing penalty – From the Delinquent Filing Penalty Calculation Worksheet,

page 16, Line 7.

Delinquent payment penalty – From the Delinquent Payment Penalty Calculation Worksheet,

page 16, Line 7.

34 Total amount due (Add Lines 30 through 33.)

PAY THIS AMOUNT.

Under the penalties of perjury, I declare that I have examined this return, including all accompanying documents, and to the best of my knowledge and belief,

it is true, correct, and complete. If prepared by a person other than taxpayer, his declaration is based on all information of which he has any knowledge.

Print Name of Fiduciary

Title of Fiduciary

Signature of fiduciary or officer representing fiduciary

Telephone

Date

(mm/dd/yyyy)

Address

City

State

ZIP

Signature of preparer other than fiduciary

Telephone