Form It-8879 - Indiana Individual Income Tax Declaration Of Electronic Filing
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1Indiana Individual Income Tax
Form
Do Not Mail
DECLARATION OF ELECTRONIC FILING
IT-8879
This Form
Income Tax For the tax year January 1 - December 31, 2009
State Form 53399
(R3 / 10-09)
DCN
Submission ID
First Name(s) and Middle Initial(s)
Last Name
Your Social Security Number Spouse’s Social Security Number
Spouse’s First Name(s) and Middle
Spouse’s Last Name
Street Address
Initial(s)
City
State
Zip Code
Daytime Telephone Number
Tax Return Information (Whole Dollar Amounts Only)
Part I
1. Federal Adjusted Gross Income (Form IT-40, Line 1 or IT-40EZ, Line 1) ...................................
1.
2. Indiana taxable income (Form IT-40, Line 7 or IT-40EZ, Line 7) .................................................
2.
3. Total Indiana tax (Form IT-40, Line 11 or IT-40EZ, Line 11) ........................................................
3.
4. Total state tax withheld (Form IT-40, Schedule 5, Line 1 or IT-40EZ, Line 12) ...........................
4.
5. Total county tax withheld (Form IT-40, Schedule 5, Line 2 or IT-40EZ, Line 13) .........................
5.
6. Total Indiana tax credits (Form IT-40, Line 14 or IT-40EZ, Line 15) ............................................
6.
7. Refund (Form IT-40, Line 21 or IT-40EZ, Line 18) ......................................................................
7.
8. Amount you owe (Form IT-40, Line 26 or IT-40EZ, Line 23) .......................................................
8.
Part II
Direct Deposit
9. Routing number
Note: The fi rst two digits of the routing number must be 01 - 12 or 21 - 32.
Do Not Mail
10. Account number
□
□
□
This Form
11. Type of account:
Checking
Savings
Hoosier Works MC
My request for direct deposit of my refund includes my authorization for the Indiana Department of Revenue to furnish my fi nancial institution
with my routing number, account number, account type, and social security number to insure my refund is properly deposited.
Part III
Declaration of Taxpayer
Under penalties of perjury, I declare that the information I have given my ERO and the amounts in Part I above agree with the amounts on the
corresponding lines of the electronic portion of my income tax return. To the best of my knowledge and belief, my 2009 return is true correct and
complete. I consent to my ERO sending my return, this declaration, and accompanying schedules and statements to the IDOR. I also consent
to the IDOR sending my ERO and/or transmitter an acknowledgement of receipt of transmission and an indication of whether or not my return is
I
accepted, and, if rejected, the reason(s) for the rejection. If the processing of my return or refund is delayed, I authorize the IDOR to disclose to
my ERO and/or transmitter the reason(s) for the delay of when the refund was sent.
N
Taxpayer’s PIN: check one box only
□
I authorize _______________________ to enter my PIN
as my signature on my tax year 2009 electronically fi led
D
income tax return.
do not enter all zeros
□
I will enter my PIN as my signature on my tax year 2009 electronically fi led income tax return. Check this box only if you are entering your
I
own PIN and your return is fi led using the Practitioner PIN method. The ERO must complete part IV below.
A
Taxpayer’s signature ► ____________________________________ Date ____________________________________
Spouse’s PIN: check one box only
N
□
I authorize _______________________ to enter my PIN
as my signature on my tax year 2009 electronically fi led
income tax return.
do not enter all zeros
A
□
I will enter my PIN as my signature on my tax year 2009 electronically fi led income tax return. Check this box only if you are entering your
own PIN and your return is fi led using the Practitioner PIN method. The ERO must complete part IV below.
Spouse’s signature ► _____________________________________ Date ____________________________________
Part IV
Practitioner Certifi cation and Authentication - Practitioner PIN Method ONLY
ERO’s EFIN/PIN. Enter your six-digit EFIN followed by your fi ve-digit self selected PIN.
do not enter all zeros
I certify that the above numeric entry is my PIN, which is my signature for the tax year 2009 electronically fi led income tax return for the
taxpayer(s) indicated above. I confi rm that I am submitting this return in accordance with the requirements of the Practitioner PIN method.
ERO’s Signature ► _______________________________________ Date ___________________________________
ERO Must Retain This Form - See instructions Do Not Submit this form to IDOR unless requested to do so.
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