Form Sc-40 - Unified Tax Credit For Rhe Elderly - 2015
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1Unified Tax Credit for the Elderly
FORM
SC-40
2016
Married Claimants Must File Jointly
State Form 44404
(R15 / 9-16)
You Must File This Form by June 30, 2017
Y
Your Social Security Number
our first name
Initial
Last name
Spouse’s first 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
2016
2016
M
M
D
D
M
M
D
D
□
□
1. Check box if you were age 65 or older by Dec. 31, 2016
Check box if spouse was age 65 or older by Dec. 31, 2016
□
□
2. Were you a resident of Indiana for six months or more during 2016?
Yes
No
3. Was your spouse a resident of Indiana for six months or more during 2016?
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.
00
A.
Wages, salaries, tips and commissions, unemployment compensation, etc .............................
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 benefits) ..............................................
D
00
E.
Total income (Add Lines A through D and enter the total here) ...............................................
E
00
F.
Your Refund (See chart on back to figure your refund) ..........................................................
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 file an Indiana income tax return.
__________________________________________
_________________________________________
Your Signature
Date
Spouse's Signature
Date
Daytime Telephone Number
□
□
I authorize the department to discuss my return with my
Paid Preparer: Firm’s Name (or yours if self-employed)
personal representative
Yes
No
If yes, complete the information below.
______________________________________________________
□
Personal Representative’s Name (please print)
PTIN
____________________________________________________
Telephone
number
Address _____________________________________________
Address _______________________________________________
City ________________________________________________
City __________________________________________________
State _____________________
Zip Code + 4 ___________
State _______________________
Zip Code + 4 ___________
*16216111694*
16216111694
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