Form Sc-40 - Unified Tax Credit For The Elderly - 2010
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1Unifi ed Tax Credit for the Elderly
FORM
SC-40
2010
Married Claimants Must File Jointly
State Form 44404
(R9 / 9-10)
You Must File This Form by June 30, 2011
Y
Your Social Security Number
our fi rst name
Initial
Last name
Spouse’s fi rst name
Initial
Last name
Spouse’s Social Security Number
Present address (number and street or rural route)
Taxpayer’s date of death
Spouse's date of death
City or Town
State
Zip/Postal code
2010
2010
M
M
D
D
M
M
D
D
□
□
1. Check box if you were age 65 or older by Dec. 31, 2010
Check box if spouse was age 65 or older by Dec. 31, 2010
□
□
2. Were you a resident of Indiana for six months or more during 2010?
Yes
No
3. Was your spouse a resident of Indiana for six months or more during 2010?
Yes
No
Determine Your Income
Certain income, such as Social Security, veteran’s disability pensions and life insurance proceeds, should not be entered on this form.
Enter all other income received by you and your spouse during the tax year. Complete all spaces. If you had no income from any of the
sources listed below, place a zero (-0-) in the space provided. Round all entries.
A.
Wages, salaries, tips and commissions ....................................................................................
A
00
B.
Dividend and interest income ....................................................................................................
B
00
C. Net gain or loss from rental income, business income, etc .......................................................
C
00
D. Pensions or annuities (Do not enter Social Security benefi ts) ..............................................
D
00
Total income (Add Lines A through D and enter the total here) ...............................................
E
00
E.
Your Refund (See chart on back to fi gure your refund) ..........................................................
F
00
F.
□
□
G. Direct Deposit (1) Routing Number
(3)
Checking (4)
Savings
(2) Account Number
□
(5) Place an "X" in the box if refund will go to an account outside the United States.
Under penalty of perjury, I (we) have examined this return and to the best of my (our) knowledge and belief, it is true, complete, and correct
and that I am (we are) not required to fi le an Indiana income tax return.
__________________________________________
_________________________________________
Your Signature
Date
Spouse's Signature
Date
Daytime Telephone Number
Paid Preparer: Firm’s Name (or yours if self-employed)
□
□
I authorize the Department to discuss my return with my
personal representative
Yes
No
______________________________________________________
If yes, complete the information below.
Personal Representative’s Name (please print)
□
□
□
Federal I.D. Number
PTIN OR
Social Security Number
____________________________________________________
Telephone
number
Address _____________________________________________
Address _______________________________________________
City ________________________________________________
City __________________________________________________
State _____________________
Zip Code + 4 ___________
State _______________________
Zip Code + 4 ___________
16210111694
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