WH-5 State Form 51021 R7 / 9-08 Indiana Earned Income Credit Advance Payment Certificate 2009 Use the current year’s certificate only. Give this certificate to your employer. This certificate expires on December 31, 2009. Print or type your full name Your social security number / / Note: To get advance payments of the Indiana earned income credit, your employer must be withholding advance payments for federal income tax purposes. If you get Indiana advance payments of the earned income credit for 2009, you must file a 2009 Indiana income tax return. You must answer yes to all four of the following questions to be eligible for Indiana advance payments: 1. 2. 3. 4. I am an Indiana resident ................................................................................................ Yes I have a federal Form W-5 on file with my employer ...................................................... Yes I am receiving federal advance earned income credit payments from my employer ...... Yes I choose to receive Indiana advance earned income credit payments .......................... Yes □ □ □ □ No No No No □ □ □ □ Under penalties of perjury, I declare that the information I have furnished above is, to the best of my knowledge, true, correct and complete. Signature Date WH-5 State Form 51021 R7 / 9-08 Indiana Earned Income Credit Advance Payment Certificate 2009 Use the current year’s certificate only. Give this certificate to your employer. This certificate expires on December 31, 2009. Print or type your full name Your social security number / / Note: To get advance payments of the Indiana earned income credit, your employer must be withholding advance payments for federal income tax purposes. If you get Indiana advance payments of the earned income credit for 2009, you must file a 2009 Indiana income tax return. You must answer yes to all four of the following questions to be eligible for Indiana advance payments: 1. 2. 3. 4. I am an Indiana resident ................................................................................................ Yes I have a federal Form W-5 on file with my employer ...................................................... Yes I am receiving federal advance earned income credit payments from my employer ...... Yes I choose to receive Indiana advance earned income credit payments .......................... Yes □ □ □ □ No No No No □ □ □ □ Under penalties of perjury, I declare that the information I have furnished above is, to the best of my knowledge, true, correct and complete. Signature Date American LegalNet, Inc. www.FormsWorkflow.com