Form It-40pnr - Schedule H - Residency Information - 2012 Page 2
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1
2Schedule H
Schedule H Section 2:
Enclosure
2012
Form IT-40PNR
Sequence No. 07A
Additional Required Information
State Form 54035
Page 2 of 2
Instructions begin on page 56.
(R3 / 9-12)
Section 2: Additional Information
1. Federal fi ling information
Are you fi ling a federal income tax return for 2012? Place “X” in appropriate box. Yes
No
2. Extension of time to fi le
a. Place “X” in box if you have fi led a federal extension of time to fi le, Form 4868.
b. Place “X” in box if you have fi led an Indiana extension of time to fi le, Form IT-9, or online via ePay.
3. Farm / Fishing income
Place “X” in box if at least two-thirds of your gross income was made from farming or fi shing.
Important: If you placed an “X” in the box, you MUST attach Schedule IT-2210.
4. Date of death
If any individual listed at the top of the IT-40PNR died during 2012, enter date of death (MM/DD).
2012
2012
Taxpayer’s date of death
Spouse’s date of death
Authorization Sign Form IT-40PNR after reading the following statement.
Under penalty of perjury, I have examined this return and all attachments and to the best of my knowledge and belief, it is true, com-
plete 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 to furnish my fi nancial 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 confi rm that the
Social Security number(s) used on this return is correct.
5. Your daytime telephone number
Your e-mail address
I authorize the Department to discuss my return with my personal
Paid Preparer: Firm’s Name (or yours if self-employed)
representative (see page 56 ).
Yes
No
If yes, complete the information below.
Personal Representative’s Name (please print)
IN-OPT on fi le with paid preparer if not fi ling electronically
PTIN
Telephone
number
Address
Address
City
City
State
Zip Code
State
Zip Code
24012121694
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