DCN Do Not Mail This Form Indiana Individual Income Tax IT-8453OL DECLARATION OF ELECTRONIC FILING State Form 46201 Form For the tax year January 1 - December 31, 2008 (R7 / 8-08) First Name(s) and Middle Initial(s) Last Name Your Social Security Number Spouse’s First Name(s) and Middle Initial(s) Last Name Spouse’s Social Security Number Street Address Apartment Number City State Part I Zip Code Daytime Telephone Number Tax Return Information (Whole Dollar Amounts Only) t o N o il D a M 1. Federal Adjusted Gross Income (Form IT-40, Line 1 or IT-40EZ, Line 1) ................... 1. 2. Indiana taxable income (Form IT-40, Line 15 or IT-40EZ, Line 5) .............................. 2. 3. Total Indiana tax (Form IT-40, Line 22 or IT-40EZ, Line 9) ......................................... 3. 4. Total state tax withheld (Form IT-40, Line 23 or IT-40EZ, Line 10) ............................ 4. 5. Total county tax withheld (Form IT-40, Line 24 or IT-40EZ, Line 11) .......................... 5. 6. Total Indiana tax credits (Form IT-40, Line 32 or IT-40EZ, Line 13) ........................... 6. 7. Refund (Form IT-40, Line 40 or IT-40EZ, Line 16) ..................................................... 7. 8. Amount you owe (Form IT-40, Line 45 or IT-40EZ, Line 21) ...................................... 8. Attach W-2 Forms Here Part II 9. Routing number 10. Account number 11. Type of account: Direct Deposit Note: The first two digits of the routing number must be 01 - 12 or 21 - 32. Do Not Mail This Form □ 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 financial 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 If I have filed a balance due return, I understand that if the IDOR does not receive full and timely payment of my tax liability, I will remain liable for the tax liability and all applicable interest and penalties. Under penalties of perjury, I declare that the amounts in Part I above agree with the amounts on the corresponding lines of the electronic portion of my 2008 income tax return. To the best of my knowledge and belief, my return is true correct and complete. I consent to allow my transmitter to send my return, this declaration, and accompanying schedules and statements to the IDOR. I also consent to the IDOR sending an acknowledgement of receipt of transmission and an indication of whether or not my return is accepted, and, if rejected, the reason(s) for the rejection. Please sign here ► _________________________ Taxpayer’s Signature ____________ Date __________________________ Spouse’s Signature ___________ Date American LegalNet, Inc. www.FormsWorkflow.com I N D I A N A IT-8453OL Purpose of this form This form is to be completed and signed by the taxpayer before their return can be filed electronically through the Federal/ State On-Line Filing Program. The On-Line Software will: 1. Enter the Document Control Number (DCN) assigned to the electronic tax return in the field provided at the top of the form. 2. Fill in the taxpayer’s (and spouse’s if filing a joint return) name, address, social security number, and daytime telephone number where indicated at the top of the form. 3. Complete Part I, using the amounts from the taxpayer’s Indiana individual income tax return. 4. Complete Part II, if the taxpayer elects to have their refund direct deposited into their financial institution savings or checking account or deposited into their Hoosier Works Card. The Taxpayer will: 1. Complete Part III, with their signature and date. 2. Mail nothing into the Indiana Department of Revenue, unless requested by the department. 3. Keep and maintain the IT-8453OL for three (3) years from December 31st of the year the return was signed. t o N o il D a M American LegalNet, Inc. www.FormsWorkflow.com