Form It-40pnr - Schedule H - Residency Information - 2012
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1
2Schedule H
Schedule H Section 1: Residency Information
Enclosure
2012
Form IT-40PNR
(Complete Section 2: Additional Information on back)
Sequence No. 07
State Form 54035
Page 1 of 2
(R3 / 9-12)
Name(s) shown on Form IT-40PNR
Your Social Security Number
Section 1: Residency
List all state(s)and dates of your (and your spouse’s, if fi ling jointly) residency during 2012. Enter 2-letter
state name (e.g. “IL” for Illinois) or the letters “OC” if you were a resident of a foreign country. Instructions
Information
begin on page 56.
Example
State of
Date From
Date To
Did you fi le a tax return with the state/country?
Residence
(MM/DD)
(MM/DD)
Place “X” in appropriate box.
IL
01
01
2012
06
01
2012
X
Yes
No
IN
06
02
2012
12
31
2012
X
Yes
No
Your information
(a)
(b)
(c)
State of
Date From
Date To
Did you fi le a tax return with the state/country?
Residence
(MM/DD)
(MM/DD)
Place “X” in appropriate box.
2012
2012
1A
Yes
No
2012
2012
1B
Yes
No
2012
2012
1C
Yes
No
2012
2012
1D
Yes
No
Spouse’s information if married fi ling jointly
(a)
(b)
(c)
State of
Date From
Date To
Did you fi le a tax return with the state/country?
Residence
(MM/DD)
(MM/DD)
Place “X” in appropriate box.
2012
2012
2A
Yes
No
2012
2012
2B
Yes
No
2012
2012
2C
Yes
No
2012
2012
2D
Yes
No
Turn over to complete Section 2
24012111694
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