Form It-40x - Indiana Amended Individual Income Tax Return - 2011 Page 2
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2Part IV - Refund or Amount Due
00
Your Refund
21. Refund: If line 20 is greater than line 12, enter the difference here ....................................
21
00
22. Amount Due: If line 12 is greater than line 20, enter the difference here ..................................................
22
00
23. Penalty (10% of line 22) ..............................................................................................................................
23
00
24. Interest (see instructions for the rate)..........................................................................................................
24
Pay This Amount
00
25. Total Amount Due (
25
see instruction page for information on how to make your payment) .....
Authorization
Under penalty of perjury, I have examined this return and all attachments and to the best of my knowledge and belief, it is true, complete and
correct. I understand that if this is a joint return, any refund will be made payable to us jointly and each of us is liable for all taxes due under this
return. Also, my request for direct deposit of my refund includes my authorization to the Indiana Department of Revenue (Department) to furnish my
fi nancial institution with my routing number, account number, account type, and Social Security number to ensure my refund is properly deposited.
I give permission to the Department to contact the Social Security Administration to confi rm that the Social Security number(s) used on this return
is correct.
Daytime telephone number
Your Signature ______________________________________
Date _____________
E-mail address where we can reach you
Spouse’s Signature __________________________________
Date _____________
I authorize the Department to discuss my return with my personal
Paid Preparer: Firm’s Name (or yours if self-employed)
representative.
Yes
No
If yes, complete the information below.
Personal Representative’s Name (please print)
Federal I.D. Number
PTIN OR
Social Security No.
Telephone
number
Address
Address
City
City
State
Zip Code
State
Zip Code
Enter a detailed explanation of your changes. Enclose supporting forms, schedules and other appropriate documentation, such as
additional W-2 forms, corrected federal schedules, Schedule IT-40NOL, etc.
Mailing Address:
• If enclosing payment mail to: Indiana Department of Revenue, P.O. Box 7224, Indianapolis, IN 46207-7224.
• Mail all other returns to: Indiana Department of Revenue, P.O. Box 40, Indianapolis, IN 46206-0040.
24100000000
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