Form It-40 - Indiana Full-Year Resident Individual Income Tax Return - 2004 Page 4
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4Schedule IN-EIC
Schedule IN-EIC: Indiana’s Earned Income Credit
Attachment
Form IT-40/IT-40PNR
Sequence No. 05
Attach only if claiming this credit on Forms IT-40 or IT-40PNR
State Form 49469 R 3/10-04
A
Enter your first name, middle initial and last name and spouse’s full name if filing a joint return
Your Social
Security Number
Section A: Figure Your Indiana Earned Income Credit
Enter the earned income credit from your federal income tax return Form 1040 line 65a,
A-1
Form 1040A line 41a, or Form 1040EZ line 8a (must be $9.00 or more: see instructions) .................... A1$_____________
Multiply line A1 by .06 and enter here. Carry this total to Form IT-40, line 25, or
A-2
Form IT-40PNR, line 22 ...................................................................... Indiana Earned Income Credit A2$_____________
If you did not complete Federal Schedule EIC (you did not claim children when figuring your federal earned income
credit), you are finished with this schedule. Make sure to attach it to your Form IT-40 or IT-40PNR.
If you claimed children on your Federal Schedule EIC
Complete Section B if you claimed children (on Federal Schedule EIC) when you figured your earned income credit on
federal Forms 1040 or 1040A. Enter information for up to four children even if only claiming two on federal Schedule EIC
(see instructions for more information).
Section B: Qualifying Child (Read the instructions to explain the terms used below.)
3
2
4
1
First
First
First
First
Enter each child’s name here
Last
Last
Last
Last
Enter each child’s
SSN
SSN
SSN
SSN
Social Security Number
-
-
-
-
-
-
-
-
Check only one box in each section for each child listed.
a
a
a
a
Your child
b
b
b
b
Adopted child
c
c
c
c
Grandchild
B-1
d
d
d
d
Stepchild
e
e
e
e
Foster child, (not related)
Other (related foster child, or
f
f
f
f
other related child - see instructions)
g
g
Under age 18
g
g
h
h
h
Age 18
h
B-2
i
i
i
Age 19 - 24 and a full-time student
i
j
j
j
Age 19 or older and totally disabled
j
Child lived with you at least 1/2 of the
k
k
k
k
year.
B-3
Child was born or died in 2004,
and lived with you while alive in 2004.
l
l
l
l
Important: You must complete and attach this schedule to your Form IT-40 or IT-40PNR when claiming the
Indiana earned income credit. Note: Do not complete or attach this schedule if you are claiming this credit on the
Form IT-40EZ (see the worksheet on Form IT-40EZ for instructions for how to claim the credit).
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