Form It-41 (State Form 11458) - Fiduciary Income Tax Return Page 2

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Name of Estate or Trust

Federal Identification Number

Check Applicable Boxes

First Return

Final Return

Amended Return

Fiduciary Name Change

Address Change

Check Applicable Boxes

Retirement Plan

Estate

Simple Trust

Complex Trust

Bankruptcy Estate

ESBT Trust

Grantor Trust

Other (Please Specify)

Additional Information - Please answer the following questions or provide the requested information

1. Is there a non-resident beneficiary? Yes

2. How many Schedule K-1s are enclosed with this return?

3. If this is an estate return, enter the date of the decedent’s death and Social Security number

Decedent’s date of death

Decedent’s Social Security Number

4. If this is a trust return, enter date the entity was created

5. Was a final individual return filed for decedent? Yes

6. If this is a grantor trust return, enter the grantor’s Social Security number

I authorize the Department to discuss my return with my personal

Address

representative.

Yes

If yes, complete the information below.

City

Personal Representative’s Name (please print)

State

Zip Code

Telephone

Number

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is true,

correct, and complete. If prepared by a person other than the taxpayer, this declaration is based upon all information of which the preparer has any knowledge.

Signature of Fiduciary or Officer

Telephone Number

Date

Mail completed return with

payment to:

Signature of Preparer

Telephone Number

Date

Indiana

Department of

Revenue

Fiduciary Section