Retiree Refund Claim Form - Arkansas Individual Income Tax

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RETIREE REFUND CLAIM FORM
McFadden vs. Weiss
Claimant’s Social Security Number:
_______ - ______ - ____________
Claimant’s Name:
__________________________________________________
Retiree’s Name: (if different)
_________________________________________
Current Address:
______________________________________________
City, State, Zip:
______________________________________________
Source of Retirement Benefits:
Federal Agency
State
Private Employer
Annuity Commencement Date: (ACD)
_________________ (mm/dd/yyyy)
Type of annuity: (Check Only One)
Regular Annuity:
_______
Survivor Annuity:
_______
Retiree’s Date of Birth:
_________________ (mm/dd/yyyy)
Beneficiary’s Date of Birth: (if applicable)
_________________ (mm/dd/yyyy)
*
Original Cost of Contribution:
$ _________________
(See 1099R, Statement of Annuity Paid)
Calculated Recovery Period: (Leave Blank)
_________________
Qualifying Gross Annuity Amount Received:
(See 1099R, Statement of Annuity Paid)
_______________
________________
________________
_______________
1999
2000
2001
2002
Do not include any income from other sources. If you are married, and your spouse also has qualifying retirement income, he/she/ must file a separate claim.
Did you participate in an “Alternative Annuity” program where you received all or part of Your original contribution at the time of
retirement?
YES
NO
__________________________________________________________________________________________________
Your Signature
Date
Telephone Number(s) (Daytime and Evening)
Mail Claim Form To :
Arkansas Individual Income Tax
McFadden Retiree Refund Claim Unit
P. O. Box 8110
Little Rock, AR 72203
*
This only applies to amounts you contributed on an after tax basis. If you are not sure about the tax status of your cost of
contribution, please contact your tax preparer.
(REV 04/29/05)

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