Form Schedules 3-4 Exemptions and Other Taxes

who you are eligible to claim as a dependent on your federal tax return 1 Number of exemptions claimed on your federal return 2 Claim an additional exemption for each dependent child 23012111694 3 Place X in box(es) below if by December 31 2012 You were age 65 or older 4 If age 65 or older enter amount from Form IT 40 line 1 $ If this amount is less than $40 000 place X in box(es) below if: You were age 65 or older 5 Add lines 1 2 3 and 4 Enter here and on Form IT 40 line 6 Total Exemptions Add lines 1 through 3 Enter here and on Form IT 40 line 10 Total Other Taxes and/or blind Enter number you are eligible to claim Form IT 40 State Form 53997 (Schedule 4 begins after line 5 below) 2012 Sequence No 03 (R3 / 9 12) Household employment taxes Enclose Schedule IN H If you did not claim an exemption on your federal return enter 1 in the box above Instructions begin on page 27 Name(s) shown on Form IT 40 Your Social Security Number OffOff Recapture of Indiana s CollegeChoice 529 credit Enclose Schedule IN 529R Round all entries Schedule 4: Other Taxes Schedules 3 & 4 Schedule 3: ExemptionsEnclosure See instructions on page 26 if you did not le a federal return Spouse was 65 or older Total number of boxes with Xs Use tax on out of state purchases from line 4 of Sales/Use Tax Worksheet who is a son stepson daughter stepdaughter and/or foster child who was under the age of 19 by Dec 31 2012 or a full time student who was under the age of 24 by Dec 31 2012 and x $1 000 x $1000 x $1500: you MUST enclose Schedule IN DEP x $500