File by Mail Instructions for your 2022 Indiana Amended Tax Return

Important: Your taxes are not finished until all required steps are completed.

todd M Gillz, jr
7505 N 200 E
Alexandria, IN 46001-8728
|
Balance | Your Indiana state amended tax return shows you are due a refund of
Due/ | $298.00.
Refund |
|
______________________________________________________________________________________
|
What You | Your amended tax return - Form IT-40 Amended. Remember to sign
Need to | and date the return.
Mail |
| Be sure to attach a copy of your amended federal return, if one was
| filed, and any schedules and forms that support the changes on your
| Indiana Amended Income Tax Return.
|
| Mail your return and attachments to:
| Indiana Department of Revenue
| P.O. Box 40
| Indianapolis, IN 46206-0040
|
| Don't forget correct postage on the envelope.
|
______________________________________________________________________________________
|
What You | Keep these instructions and a copy of your return for your records.
Need to | You can download or print a copy of your return by logging into your
Keep | TurboTax account.
|
______________________________________________________________________________________
|
2022 | Adjusted Gross Income Correct Amount $ 6,741.00
Indiana | Taxable Income Correct Amount $ 5,741.00
Tax | Total Tax Correct Amount $ 271.00
Return | Total Payments/Credits Correct Amount $ 569.00
Summary | Amount to be Refunded $ 298.00
|
______________________________________________________________________________________
|
Special | Your printed state tax forms may have special formatting on them,
Formatting | such as bar codes or other symbols. This is to enable fast
| processing. Don't worry, these forms have been approved by your
| taxing authority and are acceptable for printing and mailing.
|
______________________________________________________________________________________

Page 1 of 1
 Form Indiana Full-Year Resident
IT-40
State Form 154
2022 Individual Income Tax Return
Due April 18, 2023

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LQFRPHWD[UHWXUQ)RUPRU)RUP65OLQH _____________________ Federal AGI 1 6741.00

 (QWHUDPRXQWIURP6FKHGXOHOLQHDQGHQFORVH6FKHGXOH ________ Indiana Add-Backs 2 .00

 $GGOLQHDQGOLQH ____________________________________________________________ 3 6741.00

 (QWHUDPRXQWIURP6FKHGXOHOLQHDQGHQFORVH6FKHGXOH _______ Indiana Deductions 4 .00

 6XEWUDFWOLQHIURPOLQH ________________________________________________________ 5 6741.00

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DQGHQFORVH6FKHGXOH ______________________________________ Indiana Exemptions 6 1000.00

 6XEWUDFWOLQHIURPOLQH ____________________________ Indiana Adjusted Gross Income  5741.00

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LIDQVZHULVOHVVWKDQ]HUROHDYHEODQN ____________________ 8 185.00
 &RXQW\WD[(QWHUFRXQW\WD[GXHIURP6FKHGXOH&7
LIDQVZHULVOHVVWKDQ]HUROHDYHEODQN ____________________ 9 86.00

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 $GGOLQHVDQG(QWHUWRWDOKHUHDQGRQOLQHRQWKHEDFN ___________ Indiana Taxes 11 271.00

REV 02/17/23 Intuit.cg.cfp.sp 15122111555

 (QWHUFUHGLWVIURP6FKHGXOHOLQH HQFORVHVFKHGXOH ___ 12 569 .00

 (QWHURႇVHWFUHGLWVIURP6FKHGXOHOLQH HQFORVHVFKHGXOH  .00

 $GGOLQHVDQG ______________________________________________ Indiana Credits 14 569.00

 (QWHUDPRXQWIURPOLQH ___________________________________________ Indiana Taxes 15 271.00

 ,IOLQHLVHTXDOWRRUPRUHWKDQOLQHVXEWUDFWOLQHIURPOLQH LIVPDOOHUVNLSWROLQH  298.00

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 6XEWUDFWOLQHIURPOLQH __________________________________________Overpayment 18 298.00

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Sign and date this return after reading the Authorization statement on Schedule 7. Remember to enclose Schedule 7.

_____________________________________________________ _________________________________________________
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REV 02/17/23 Intuit.cg.cfp.sp 15122121555

 Schedule 3 Schedule 3: Exemptions Enclosure
Form IT-40, State Form 53997
(R13 / 9-22)
2022 Sequence No. 03

Name(s) shown on Form IT-40 Your Social Security Number

TODD M GILLZ, JR 313 74 4792

Complete and enclose Schedule IN-DEP: Dependent Information and Additional Dependent Child Information if you are claiming
dependents on lines 2 and/or 3 below. Complete and enclose Schedule IN-DEP-A: Adopted Dependent Information if you are
claiming dependents on line 6 below.
Round all entries

1. Enter $2000 if you are married filing jointly; otherwise, enter $1000_________________________ 1 1000.00

2. Enter the number of dependents listed on Schedule IN-DEP, Box 6 x $1000__________ 2 .00
You MUST enclose Schedule IN-DEP.

3. You may claim an additional exemption for each qualifying dependent child:
• who is a son, stepson, daughter, stepdaughter, foster child and/or child for whom you are a
legal guardian;
• who was under the age of 19 by Dec. 31, 2022; or
• who is a full-time student who was under the age of 24 by Dec. 31, 2022; and
• who you are eligible to claim as a dependent on line 2 above.

Enter the number of additional dependents

listed on Schedule IN-DEP, Box 7. x $1500_____________________________ 3 .00
4. Place “X” in box(es) below if, by Dec. 31, 2022

You were age 65 or older and/or blind

Spouse was 65 or older and/or blind

Total number of boxes with Xs x $1000______________________________________ 4 .00

5. If age 65 or older, enter amount from Form IT-40, line 1.

• If filing as married filing separately and this amount is less than $20,000, place “X” in
the “You were age 65 or older” box below.
• For all other filers age 65 or older, if this amount is less than $40,000, place “X” in
appropriate box(es) below.

You were age 65 or older

Spouse was 65 or older

Total number of boxes with Xs x $500________________________________________ 5 .00

6. Enter the number of additional adopted child
exemptions listed on Schedule IN-DEP-A, Box 6 x $3000_________________________ 6 .00
You MUST enclose Schedule IN-DEP-A.

7. Add lines 1, 2, 3, 4, 5 and 6. Enter here and on Form IT-40, line 6___________Total Exemptions 7 1000.00

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 Schedule 5 / Schedule IN-DONATE Schedule 5: Credits Enclosure
Form IT-40, State Form 53998
(R13 / 9-22) 2022 Sequence No. 04

Name(s) shown on Form IT-40 Your Social Security Number

TODD M GILLZ, JR 313 74 4792

Round all entries

1. Indiana state tax withheld: See instructions ___________________________________________ 1 218.00

2. Indiana county tax withheld: See instructions _________________________________________ 2 .00

3. Estimated tax paid for 2022: include any extension payment made with Form IT-9 ____________ 3 0.00

4. 8QL¿HGWD[FUHGLWIRUWKHHOGHUO\ ____________________________________________________ 4 .00

5. Earned income credit: enclose Schedule IN-EIC and enter amount from line A-3 _____________ 5 51.00

6. Lake County residential income tax credit ____________________________________________ 6 300.00

7. Economic development for a growing economy credit. Enter amount from Schedule IN-EDGE,
line 19 (enclose schedule) ________________________________________________________ 7 .00
8. Economic development for a growing economy retention credit. Enter amount from
Schedule IN-EDGE-R, line 19 (enclose schedule) ______________________________________ 8 .00

9. Headquarters relocation credit (refundable portion - see instructions)_______________________ 9 .00

10. Adoption Credit ________________________________________________________________ 10 .00

11. 2022 Additional Automatic Taxpayer Refund: See instructions ____________________________ 11 .00

12. Add lines 1 through 11. Enter total here and on Form IT-40, line 12 _____________ Total Credits 12 569.00

Schedule IN-DONATE
Important: The amount on line 2 cannot exceed the amount on Form IT-40/IT-40PNR, line 16.

1. Donations: List fund name, 3-digit code and amount to be donated (see instructions)

a. Enter fund name code no. 1a .00

b. Enter fund name code no. 1b .00

c. Enter fund name code no. 1c .00

2. Add lines 1a through 1c. Enter total here and on Form IT-40/IT-40PNR, line 17 Total Donations 2 .00

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 Schedule 7 Schedule 7: Additional Required Information Enclosure
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Name(s) shown on Form IT-40 Your Social Security Number

TODD M GILLZ, JR 313 74 4792

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 Schedule CT-40 County Tax Schedule for Enclosure
Form IT-40, State Form 47907
(R21 / 9-22) Full-Year Indiana Residents 2022 Sequence No. 07

Name(s) shown on Form IT-40 Your Social Security Number

TODD M GILLZ, JR 313 74 4792

1. Enter the amount from IT-40, line 7. Note: If both you and
your spouse lived in the same county on January 1, enter the Column A - Yourself Column B - Spouse’s
entire amount from Form IT-40, line 7 on line 1A
(do not complete Column B). See instructions_______________ 1A 5741 .00 1B .00

2. Enter the county tax rate from the chart on the back of
this schedule for the county where you lived on Jan. 1, 2022___ 2A .
0150000 2B .

3. Multiply line 1 by the rate on line 2 (leave blank if less than zero) 3A 86 .00 3B .00

4. Add lines 3A and 3B. Enter the total here. Perry County residents: If you live in Perry
County and worked in the Kentucky counties of Breckinridge, Hancock or Meade, you must
complete lines 5 and 6. Otherwise, enter the total here and on line 7 below (see instructions)_____ 4 86.00

5. Enter the amount of income that was taxed by certain Kentucky localities (see instructions)_______ 5 .00

6. Multiply line 5 by .0181 and enter total here_____________________________________________ 6 .00

7. Enter total of line 4 minus line 6. Enter this amount on line 9 of Form IT-40____________________ 7 86.00

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 Schedule IN-EIC Schedule IN-EIC: Indiana’s Earned Income Credit Enclosure
Form IT-40/IT-40PNR You must enclose if claiming this credit on Forms IT-40 or IT-40PNR. Sequence No. 9
State Form 49469
(R22 / 9-22)
2022
Name(s) shown on Form IT-40/IT-40PNR Your Social Security Number

TODD M GILLZ, JR 313 74 4792

Section A: Figure Your Indiana Earned Income Credit

A-1 Enter the earned income credit from your federal income tax return _______________________ A-1 514.00

A-2 Enter your earned income (see instructions) _________________________________________ A-2 6741.00
A-3 Enter your Indiana earned income credit (see instructions).
Carry this total to Form IT-40, Schedule 5, line 5, or
Form IT-40PNR, Schedule F, line 5, Box A_________________ Indiana Earned Income Credit A-3 51.00

Section B: Complete if you claimed one or more children on your federal Schedule EIC. See instructions.

Child 1 Child 2
Enter each child’s information
First name First name
Last name Last name

Child’s Social Security Number(s)

Enter letter (e.g., A, B, C, etc.) in boxes below that describes each child’s relationship, age and location to you.

Child 1 Child 2
B-1 Relationship:
A Your Child
B Grandchild
C Stepchild
D Foster Child (not related)
E Other (related foster child, or other
related child - see instructions)

B-2 Age:
A Under age 18
B Age 18
C Age 19 - 24 and full-time student
D Age 19 or older and totally
disabled

B-3 Location:
A Child lived with you at
least ½ of the year
B Child was born or died
in 2022, and lived with
you while alive in 2022.

Important: You must complete and attach this schedule to your Form IT-40 or IT-40PNR when claiming the earned income credit.

REV 02/17/23 Intuit.cg.cfp.sp 17222111555

 Schedule IN-W Schedule IN-W: Enclosure
Form IT-40, IT-40PNR, IT-40RNR
State Form 53056 (9-22) Indiana Withholding Statements 2022 Sequence No. 26

Name(s) shown on Form IT-40/IT-40PNR/IT-40RNR Your Social Security Number

TODD M GILLZ, JR 313744792

A B C D E F G H
Social Security Form Employer or State State Tax Local Local Tax Locality
Number Code Payer ID Number Income Withheld Income Withheld Code
1 313744792 W 87 6097477 674100 21800 00 00
2 00 00 00 00
3 00 00 00 00
4 00 00 00 00
5 00 00 00 00
6 00 00 00 00
7 00 00 00 00
8 00 00 00 00
9 00 00 00 00
10 00 00 00 00
11 00 00 00 00
12 00 00 00 00
13 00 00 00 00
14 00 00 00 00
15 00 00 00 00
16 00 00 00 00
17 00 00 00 00
18 00 00 00 00
19 00 00 00 00
20 00 00 00 00
21 00 00 00 00
22 00 00 00 00
23 00 00 00 00
24 00 00 00 00
25 00 00 00 00
Add lines 1 through 25 column E. Enter total on line 1 of
26 IT-40 Schedule 5, or line 1 of IT-40PNR Schedule F, or
line 7 of IT-40RNR.
21800
Add lines 1 through 25 column G. Enter total on line 2 of IT-40 Schedule 5, or
27
line 2 of IT-40PNR Schedule F, or line 8 of IT-40RNR. 00

Schedule IN-W Reference Chart

Form Type Form Code Form Type Form Code Form Type Form Code
W2/W2C W 1099R R 1099G U
W2G G 1099M M 1099NEC N

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