Form IN-H Indiana Household Employment Taxes

Add all line 2 amounts and enter on Part I line 1 Add all line 3 amounts and enter on Part I line 2 Employer Federal Identification Number Enter this amount on your Indiana individual income tax return on the following lines: Form IT 40 Schedule 4 line 2 Form IT 40PNR Schedule E line 2 No Stop Do not file this schedule Part II: State and County Tax Withholding pays those withholding taxes with the filing of his/her individual income tax return withholds state and county (if applicable) tax on household employees AND Yes Complete Part II on the back of this schedule Yes Go to question B (R5 / 9 11) *24100000000* 1 Enter the total State Tax withheld from Part II line 2 1 00 2 Enter the total County Tax withheld from Part II line 3 2 00 24100000000 3 Add lines 1 and 2 Enter the total here 3 00 A Did you file federal Schedule H for the tax year shown above? Attach to Form IT 40 Form IT 40PNR or Form IT 40P B Did you withhold state and/or county income tax for any household employee? C Make sure you enclose the state copy of your employee's W 2 forms Complete Part II first Carry those totals to the Part I Summary below County Code Number (2 digit) 4 County Code Number (2 digit) 4 County Tax Withheld 3 00 County Tax Withheld 3 00 Employee Name (First M I Last) Employee Social Security Number Employee Name (First M I Last) Employee Social Security Number Employer's signature Daytime telephone number Date Enclosure Enter below the employee's name and Social Security number as it appears on his/her W 2 form Attach additional pages if withholding for more than three household employees Income 1 00 Income 1 00 Indiana Household Employment Taxes Line 1 Enter the amount on which you are withholding federal income tax (also enter on W 2 boxes 16 and 18 ) Line 2 Enter the amount of Indiana state tax withheld (also enter on W 2 box 17 Also enter "IN" on W 2 box 15 ) Line 3 Enter the amount of county tax withheld (also enter on W 2 box 19 ) Line 4 Enter the 2 digit county code from Indiana Departmen tal Notice #1 for which the line 3 county tax was withheld Name of employer (as shown on individual income tax return) Employer Social Security Number Note: Get Form WH 4 and Departmental Notice #1 for detailed information on how to calculate state and county withholding amounts and to get the county code numbers This informa tion is available on our web site at www in gov/dor/3489 htm and www in gov/dor/3618 htm Part 1: Summary of Household Employment Taxes Schedule IN H Sequence No 12 State Form 48684 State Tax Withheld 2 00 State Tax Withheld 2 00 Summary This schedule should be filed by an individual who: Under penalties of perjury I declare that I have examined this schedule including accompanying statements and W 2 forms and to the best of my knowledge and belief it is true correct and complete