Form It-9 - Application For Extension Of Time To File - 2016

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Indiana Department of Revenue
Due April 18, 2017
Application for Extension of Time to File
State Form 21006
(R15 / 9-16)
Your Social
Spouse’s Social
Security Number
Security Number
Your first name
Last name
If filing a joint return, spouse’s first name
Last name
Present address (number and street or rural route)
Zip/Postal code
• Complete Part 1 if you are making an extension payment.
• Complete Part 2 if you are not making an extension payment.
Part 1: Payment Information
Complete the worksheet on the back of this form to figure the amount to pay.
1. State tax due from line J of worksheet ________________________________________State Tax
2. From line K of worksheet:
a. Enter your county code ____________________________________
b. Enter county tax ______________________________________________ Your County Tax
3. From line L of worksheet:
a. Enter spouse’s county code (if different from yours) ______________
b. Enter spouse’s county tax __________________________________ Spouse’s County Tax
4. Add lines 1, 2b and 3b ____________________________________________ Extension Payment
• Please make your check or money order payable to: Indiana Department of Revenue.
See instructions for other payment options.
Part 2: Nonpayment Information
1. Place an “X” in the box if you are not intending to make a payment with this form __________________________ No Payment
Do not attach Form IT-9 to your tax return when filing.
Mail entire form with any payment due by April 18, 2017, to:
Indiana Department of Revenue
P.O. Box 6117
Indianapolis, IN 46206-6117


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