Form Es-40 - Estimated Tax Payment Form - 2012
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2Form
Indiana Department of Revenue
2012
Estimated Tax Payment Form
ES-40
State Form 46005
(R10 / 9-11)
Your Social
Spouse’s Social
Security Number
Security Number
Your first name
Initial
Last name
If filing a joint return, spouse’s first name
Initial
Last name
Present address (number and street or rural route)
City
State
Zip/Postal code
Estimated Tax Designation and Payment Area
Complete the worksheet on the back of this form to figure your estimated tax payment.
.00
1. State tax due from line J of worksheet ________________________________________State Tax
1
2. From line K of worksheet:
a. Enter your county code ____________________________________
.00
b. Enter county tax ______________________________________________ Your County Tax
2b
3. From line L of worksheet:
a. Enter spouse’s county code (if different from yours) ______________
.00
b. Enter spouse’s county tax __________________________________ Spouse’s County Tax
3b
.00
4. Add lines 1, 2b and 3b ______________________________ Estimated Tax Installment Payment
4
•
Please make your check or money order payable to: Indiana Department of Revenue.
See instructions for other payment options.
Installment Period Information
Place an “X” in the appropriate box to show which payment you are making:
1
Installment payment due April 17, 2012
2
Installment payment due June 15, 2012
st
nd
3
Installment payment due Sept. 17, 2012
4
Installment payment due Jan. 15, 2013
rd
th
Mail entire form and payment to:
Indiana Department of Revenue
P.O. Box 6102
Indianapolis, IN 46206-6102
*14911111694*
14911111694
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