State Form 51021 - Indiana Earned Income Credit Advance Payment Certificate - 2009
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1WH-5
Indiana Earned Income Credit
State Form 51021
Advance Payment Certifi cate
2009
R7 / 9-08
Use the current year’s certifi cate only.
Give this certifi cate to your employer.
This certifi cate expires on December 31, 2009.
Print or type your full name
Your social security number
/
/
Note: To get advance payments of the Indiana earned income credit, your employer must be withholding advance
payments for federal income tax purposes. If you get Indiana advance payments of the earned income credit
for 2009, you must fi le a 2009 Indiana income tax return.
You must answer yes to all four of the following questions to be eligible for Indiana advance payments:
□
□
1.
I am an Indiana resident ................................................................................................ Yes
No
□
□
2.
I have a federal Form W-5 on fi le with my employer ...................................................... Yes
No
□
□
3.
I am receiving federal advance earned income credit payments from my employer ...... Yes
No
□
□
4.
I choose to receive Indiana advance earned income credit payments .......................... Yes
No
Under penalties of perjury, I declare that the information I have furnished above is, to the best of my knowledge, true,
correct and complete.
Signature
Date
WH-5
Indiana Earned Income Credit
State Form 51021
Advance Payment Certifi cate
2009
R7 / 9-08
Use the current year’s certifi cate only.
Give this certifi cate to your employer.
This certifi cate expires on December 31, 2009.
Print or type your full name
Your social security number
/
/
Note: To get advance payments of the Indiana earned income credit, your employer must be withholding advance
payments for federal income tax purposes. If you get Indiana advance payments of the earned income credit
for 2009, you must fi le a 2009 Indiana income tax return.
You must answer yes to all four of the following questions to be eligible for Indiana advance payments:
□
□
1.
I am an Indiana resident ................................................................................................ Yes
No
□
□
2.
I have a federal Form W-5 on fi le with my employer ...................................................... Yes
No
□
□
3.
I am receiving federal advance earned income credit payments from my employer ...... Yes
No
□
□
4.
I choose to receive Indiana advance earned income credit payments .......................... Yes
No
Under penalties of perjury, I declare that the information I have furnished above is, to the best of my knowledge, true,
correct and complete.
Signature
Date
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