Form Sc-40 - Unified Tax Credit For The Elderly - 2003

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Unified Tax Credit for the Elderly
FORM
SC-40
State Form 44404
Married Claimants
8-03
Must File Jointly
Tax Year: 2003
You Must File This Form by June 30, 2004
Do Not Write Above
Your Social Security Number
Your First Name, Middle Initial, Last Name
Spouse’s Social Security Number
Spouse’s First Name, Middle Initial, Last Name
If Taxpayer died during 2003,
Present Address (Number and street or rural route)
enter date of death
/
/ 2003
If Spouse died during 2003,
City or Town
State Zip Code
enter date of death
/
/ 2003
1. Your age as of December 31, 2003
Spouse’s age as of December 31, 2003
2. Were you a resident of Indiana for six months or more during 2003?
Yes
No
3. Was your spouse a resident of Indiana for six months or more during 2003?
Yes
No
Determine Your Income
Certain income, such as social security, veteran’s pensions and benefits, and life insur-
ance proceeds, should not be entered on this form. Enter all other income received by
you and your spouse during the tax year. Complete all spaces. If you had no income
from any of the sources listed below, place a zero (-0-) in the space provided.
A. Wages, salaries, tips and commissions .................................
A
B. Dividend and interest income ................................................
B
C. Net gain or loss from rental income, business income, etc ...
C
D. Pensions or annuities
.....
(Do not enter social security benefits)
D
E. Total income
.......
(Add Lines A through D and enter the total here)
E
00
F. Your Refund
..............
(See chart on back to figure your refund)
F
Under penalty of perjury, I (we) have examined this return and to the best of my (our) knowledge
and belief, it is true, complete, and correct and that I am (we are) not required to file an Indiana
income tax return.
I authorize the Department to discuss
my return with my preparer.
Your Signature
Date
I DO NOT authorize the Department to
discuss my return with my preparer.
Spouse’s Signature
Date
Paid Preparer’s Signature
(
)
Daytime Telephone Number
Paid Preparer’s Identification Number
AA

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