Form It-40pnr - Schedule H - Residency Information/additional Required Information - 2016
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1
2Schedule H Section 1: Residency Information
Schedule H
Enclosure
2016
Form IT-40PNR
(Complete Section 2: Additional Information on back)
Sequence No. 07
State Form 54035
Page 1 of 2
(R7 / 9-16)
Name(s) shown on Form IT-40PNR
Your Social Security Number
Section 1: Residency
List all state(s)and dates of your (and your spouse’s, if filing jointly) residency during 2016. Enter 2-letter
state name (e.g. “IL” for Illinois) or the letters “OC” if you were a resident of a foreign country (see instructions).
Information
Example
State of
Date From
Date To
Did you file a tax return with the state/country?
Residence
(MM/DD)
(MM/DD)
Place “X” in appropriate box.
2016
2016
IL
01
01
06
01
X
Yes
No
2016
2016
IN
06
02
12
31
X
Yes
No
Your information
(a)
(b)
(c)
State of
Date From
Date To
Did you file a tax return with the state/country?
Residence
(MM/DD)
(MM/DD)
Place “X” in appropriate box.
2016
2016
1A
Yes
No
2016
2016
1B
Yes
No
2016
2016
1C
Yes
No
2016
2016
1D
Yes
No
Spouse’s information if married filing jointly
(a)
(b)
(c)
State of
Date From
Date To
Did you file a tax return with the state/country?
Residence
(MM/DD)
(MM/DD)
Place “X” in appropriate box.
2016
2016
2A
Yes
No
2016
2016
2B
Yes
No
2016
2016
2C
Yes
No
2016
2016
2D
Yes
No
Turn over to complete Section 2
*24016111694*
24016111694
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