Form It-40 - Indiana Full-Year Resident Individual Income Tax Return - 2004 Page 2

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29. Enter the Total Tax from line 20 on the front of this form ..................................................................
29
30. Enter the Total Credits from line 28 on the front of this form ............................................................
30
31. If line 30 is more than line 29, subtract line 29 from line 30 (if smaller, skip to line 38) ...................
31
32.
Amount of line 31 to be donated to the Indiana Nongame Wildlife Fund ............................
(see instructions on page 30) ...............................................................................................
32
33. Subtract line 32 from line 31 ....................................................................................
33
SUBTOTAL
34. Amount to be applied to your 2005 estimated tax account (see instructions on page 30) ...............
34
35. Penalty for Underpayment of Estimated Tax for 2004: Attach Schedule IT-2210 or IT-2210A ........
35
36. Refund: Line 33 minus lines 34 and 35 (if less than zero see instructions on page 31)......Y
R
36
OUR
EFUND
If you want to
37a. Routing Number
DIRECT DEPOSIT
b. Account Number
your refund, see
instructions on page 31.
c. Type of Account
Checking
Savings
Hoosier Works MC
38. If line 29 is more than line 30, subtract line 30 from line 29. Add to this any amounts
38
from lines 34 and 35, and enter total here (see instructions on page 32) ............
SUBTOTAL
39
39. Penalty if filed after due date (see instructions on page 32) ............................................................
40. Interest if filed after due date (see instructions on page 32) ............................................................
40
41. Amount Due: Add lines 38, 39 and 40 ................................................................. A
Y
O
41
MOUNT
OU
WE
No payment is due if you owe less than $1.00. Do Not Send Cash. Please make your check or money order payable
to: Indiana Department of Revenue. Credit card payers must see page 32 for instructions.
Out-of-State Income Information
Taxpayer $
T
ï Enter any salary, wage, tip &/or commission received from
Spouse
$
Illinois, Kentucky, Michigan, Ohio, Pennsylvania and/or Wisconsin:
U
Taxpayer - Check box if you filed federal Schedule C or C-EZ for 2004.
V
If any individual listed at the top of the IT-40
died during 2004, enter date of death below.
Spouse
- Check box if you filed federal Schedule C or C-EZ for 2004.
W
EE
Taxpayerís
2004
ï If two-thirds of your gross income was made from farming or fishing, please check here.
X
m
m
d
d
date of death
Important: If you checked the box, you must attach Schedule IT-2210 or IT-2210A .
Spouseís date
2004
FF
of death
m
m
d
d
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
(Department) 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 in order to
confirm the social security number(s) used on this return are correct.
Your Daytime Telephone Number
Yes
No
TT
Are you filing a federal income tax return for 2004?
HH
GG
I authorize the Department to discuss my return with my tax preparer.
Yes
No
Spouseís Daytime Telephone Number
II
Your Signature
Date
JJ
E-mail address where we can reach you (see page 33)
Spouse's Signatue
Date
Paid Preparerís name
KK
OR
Federal I.D. Number,
PTIN
Social Security Number
MM
LL
Address
Preparerís daytime telephone number
NN
City
RR
OO
Preparerís Signature
Date
State
Zip Code + 4
PP
QQ
Please mail to: Indiana Department of Revenue, P.O. Box 40, Indianapolis, IN 46206-0040.
Keep a copy for your records.

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