*151551200*
Taxpayer’s Last Name
Social Security Number
* 1 5 1 5 5 1 2 0 0 *
Enter amount from Line 1 _______________________________
0 .00
Enter amount from Line 2 _______________________________
0
.00
PART B Deductions above two and a half (2.5) times the Federal Standard Deduction
.0 0
9. Enter amount of medical and dental expenses from Federal Form 1040, Schedule A, Line 4 . . . . . . . . 9. _________________________________
.0 0
10. Enter amount of gifts to charity from Federal Form 1040, Schedule A, Line 19. . . . . . . . . . . . . . . . . 10. _________________________________
If your itemized deductions are limited, go to the Department’s website for further instructions.
.0 0
11. Enter the amount of state and local income taxes from Line 4 of this schedule. . . . . . . . . . . . . . . . . . 11. _________________________________
.0 0
12. Add Lines 9 through 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. _________________________________
.0 0
13. Subtract Line 12 from Line 1 of this schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. _________________________________
.0 0
14. Multiply Line 2 of this schedule by 2.5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14. _________________________________
.0 0
15. Subtract Line 14 from Line 13. If negative, enter zero (0) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15. _________________________________
Enter this amount on Form IN-111, Line 12d.
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Important Printing Instructions
Schedule IN-155, page 2 of 2