Form It-40pnr - Schedule H - Residency Information/additional Required Information - 2015
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1
2Schedule H Section 1: Residency Information
Schedule H
Enclosure
2015
Form IT-40PNR
(Complete Section 2: Additional Information on back)
Sequence No. 07
State Form 54035
Page 1 of 2
(R6 / 9-15)
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 2015. 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.
IL
01
01
2015
06
01
2015
X
Yes
No
IN
06
02
2015
12
31
2015
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.
2015
2015
1A
Yes
No
2015
2015
1B
Yes
No
2015
2015
1C
Yes
No
2015
2015
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.
2015
2015
2A
Yes
No
2015
2015
2B
Yes
No
2015
2015
2C
Yes
No
2015
2015
2D
Yes
No
Turn over to complete Section 2
*24015111694*
24015111694
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