Form It-40rnr - Reciprocal Nonresident Indiana Individual Income Tax Return - 2009 Page 2
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1
2Information for Lake County, Indiana
If you and/or your spouse worked in Lake County, Indiana, on Jan.1, 2009, enter your and/or your spouse's 4-digit identifying
number from the Lake County Chart below.
Your 4-digit Lake County number
Spouse's 4-digit Lake County number
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, com-
plete 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 _____________
E-mail address where we can reach you
Spouse’s Signature ______________________________
Date _____________
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
□
□
□
____________________________________________________
Federal I.D. Number
PTIN OR
Social Security Number
Telephone
number
Address _____________________________________________
Address _______________________________________________
City ________________________________________________
City __________________________________________________
State _____________________
Zip Code + 4 ___________
State _______________________
Zip Code + 4 ___________
at the top of this page the 4-digit number
First, you must check the “Yes” box which
Lake County Chart
(from the chart to the left) associated with
follows the sentence “I authorize the De-
4504
Cedar Lake
4529
Lowell
that location. If you and/or your spouse
partment to discuss my tax return with my
worked in Lake County community not on
personal representative.”
4506
Crown
4530
Merrillville
the list, enter the 4-digit number 4599.
Point
Next, enter:
4511
Dyer
4531
Munster
•
Authorization/Signature Section
The name of the individual you are des-
4512
East
4532
New Chicago
If this is a joint return, both you and your
ignating as your personal representa-
Chicago
spouse must sign and date the tax re-
tive.
4513
Gary
4540
Schererville
•
turn. Please enter your daytime telephone
That person's telephone number.
•
number so we can call you if we have any
That person's complete address.
4515
Griffith
4541
Schneider
questions about your tax return. Also, en-
ter your e-mail address if you would like us
If you complete this area, you are authoriz-
4516
Hammond
4546
St. John
to be able to contact you by e-mail.
ing the Department to be in contact with
4518
Highland
4549
Whiting
someone other than you concerning in-
Personal Representative Information
formation about this tax return. After your
4519
Hobart
4550
Winfield
Typically, the Department will contact you
return is filed, the Department will commu-
(and your spouse, if filing jointly) if there
nicate primarily with your designated per-
4524
Lake
4599
Other
are any questions or concerns about your
sonal representative.
Station
Communities
tax return. If you want the Department to
be able to discuss your tax return with
Note: If you are due a refund, it will be paid
Lake County Information
someone else (e.g. the person who pre-
to you (and your spouse, if filing jointly)
If you and/or your spouse worked in Lake
pared it, a relative or friend, etc.), you’ll
even if you designate a personal repre-
County, Indiana, on Jan. 1, 2009, enter
need to complete this area.
sentative.
*160091201*
160091201
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