Form It-40x - Indiana Amended Individual Income Tax Return Page 2
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421. Refund: If line 15C is greater than line 20C, enter the difference here and stop. This is your refund. If
00
Your Refund
line 20C is greater than line 15C, continue to line 22 ...........................................................
21
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22. Amount Due: If line 20C is greater than line 15C, enter the difference here .............................................
22
00
23. Penalty (see instructions) ............................................................................................................................
23
00
24. Interest (see instructions) ............................................................................................................................
24
00
Pay This Amount
25. Total Amount Due (see instructions for information on how to make your payment)
25
.
Authorization
Under penalty of perjury, I have examined this return and all attachments and to the best of my knowledge and belief, it is true, complete and
correct. I understand that if this is a joint return, any refund will be made payable to us jointly and each of us is liable for all taxes due under this
return. Also, my request for direct deposit of my refund includes my authorization to the Indiana Department of Revenue (Department) to furnish my
financial institution with my routing number, account number, account type, and Social Security number to ensure my refund is properly deposited.
I give permission to the Department to contact the Social Security Administration to confirm that the Social Security number(s) used on this return
is correct.
Daytime telephone number
Your Signature ______________________________________
Date _____________
Email address where we can reach you
Spouse’s Signature __________________________________
Date _____________
I authorize the Department to discuss my return with my personal
Paid Preparer: Firm’s Name (or yours if self-employed)
representative.
Yes
No
If yes, complete the information below.
Personal Representative’s Name (please print)
PTIN
Address
Telephone
number
City
Address
State
Zip Code
City
Preparer’s
signature ______________________________________________
State
Zip Code
Part 1
Explanation of changes
Check all that apply. Make sure to enclose copies of W-2s, federal and/or other state tax returns, state schedules (such as CC-40 if
claiming a college credit), etc., to support your amendment.
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Add W-2 (s) __________________________________________________________________________________________
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Add/change Credit: name of credit(s) ______________________________________________________________________
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Add/change Deduction: name of deduction(s) ________________________________________________________________
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Add/change Exemption: which exemption(s) _________________________________________________________________
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Change in filing status: _________________________________________________________________________________
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Other: Explain
Mailing Address:
• If enclosing payment mail to: Indiana Department of Revenue, P.O. Box 7224, Indianapolis, IN 46207-7224.
• Mail all other returns to: Indiana Department of Revenue, P.O. Box 40, Indianapolis, IN 46206-0040.
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