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West Street, P.O. Box 237, Cloverdale, IN 46120 765-795-4261 or 800-922-6677 Section I: To Be Completed by Claimant By submitting this claim If you didn't receive a stimulus check last year (or if received less than the full amount) and your circumstances have changed such that you now qualify (or qualify for more),Rent Own Yes No 98 C = Checking or S = Savings CHECK ONE if fi ling under an extension: 4 month extension 82D 6 month extension 82F 82 88 81 FOR DOR USE ONLY 80 ADOR 91-5373 (05 . .