Form 4884 - Michigan Pension Schedule - 2016 printable pdf download

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Michigan Department of Treasury

Attach to Form MI-1040 and Schedule 1.

4884 (Rev. 05-16), Page 1 of 2

Issued under authority of Public Act 281 of 1967, as amended.

2016 MICHIGAN Pension Schedule (Form 4884)

If the filer and spouse (and deceased spouse from whom a surviving spouse is receiving benefits) were born after December 31,

1952, STOP; you are not entitled to a pension subtraction unless you have reached age 62 and receive Social Security exempt

retirement benefits. Refer to the instructions for more details.

If the older of you or your spouse was born during the period January 1, 1946 through January 1, 1950, and reached age 67 on

or before December 31, 2016, do not complete this form. Instead, complete Schedule 1, line 24.

1 4

0123456789

Type or print in blue or black ink. Print numbers like this:

- NOT like this:

Attachment 23

1. Filer’s First Name

M.I.

Last Name

2. Filer’s Full Social Security No. (Example: 123-45-6789)

If a Joint Return, Spouse’

s First Name

M.I.

Last Name

3. Spouse’s Full Social Security No. (Example: 123-45-6789)

Failure to complete this form in its entirety will result in your pension subtraction being denied.

PART 1: FILER’S AGE

4. Primary Filer Year of Birth (ex. 19xx)

5. If a Joint Return, Spouse Year of Birth (ex. 19xx)

If you are receiving retirement and pension benefits from a deceased spouse who was born prior to January 1, 1953, complete lines 6a through 6c.

6a. Deceased Spouse Name

6b. Deceased Spouse Full Social Security No.

6c. Deceased Spouse Year of Birth (ex. 19xx)

PART 2: RETIREMENT AND PENSION BENEFITS (see instructions)

Do not enter Social Security, military or railroad retirement benefits here (see Schedule 1).

Retirement and pension benefits. List all that apply for filer (and spouse if filing jointly) including benefits from a deceased spouse.

Payer FEIN (from 1099-R)

Enter “X” for

Distribution

Pension Amount

Enter “X” for

Name of Payer

Deceased

(Example: 38-1234567)

Private or Public

Code

Included in AGI

Spouse

(see instructions)

Check this box and complete the Michigan Pension Continuation Schedule (Form 4973) if you have more than ten sources of

Retirement and Pension Benefits.

Continue on page 2. This form cannot be processed if page 2 is not completed and attached.

You must also attach a completed MI-1040 and Schedule 1 when filing Form 4884.

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Form 4884 - Michigan Pension Schedule - 2016

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