Extension of time to file
Place "X" in box if you have filed a federal extension of time to file, Form 4868.
Place "X" in box if you have filed an Indiana extension of time to file, Form IT-9, or online via ePay.
Authorization
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 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 give permission to the Department to contact the Social Security Administration to confirm that the Social Security
number(s) used on this return is correct.
Daytime telephone number
Your Signature __________________________________
Date _____________
Spouse’s Signature ______________________________
Date _____________
Email address where we can reach you
I authorize the Department to discuss my return with my
Paid Preparer: Firm’s Name (or yours if self-employed)
personal representative (see below).
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: _________________________________________
• If enclosing payment mail to: Indiana Department of Revenue, P.O. Box 7224, Indianapolis, IN 46207-7224.
• Mail all other returns to: Indiana Department of Revenue, P.O. Box 40, Indianapolis, IN 46206-0040.
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