Form Nj-2440 - Statement In Support Of Exclusion For Amounts Received Under Accident And Health Insurance Plan For Personal Injuries Or Sickness

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NJ-2440
State of New Jersey
10-03, R-6
DIVISION OF TAXATION
PO BOX 019
TRENTON, NEW JERSEY 08695-0019
STATEMENT IN SUPPORT OF EXCLUSION FOR AMOUNTS RECEIVED
UNDER ACCIDENT AND HEALTH INSURANCE PLAN
FOR PERSONAL INJURIES OR SICKNESS
YEAR __________
EMPLOYEE: ______________________________________________ SOC. SEC. NO. ___________________________
EMPLOYER: ______________________________________________ I.D. NO. _________________________________
PERIODS OF SICKNESS
NUMBER
PAID
INITIAL
ALLOWABLE
DAILY RATE
FROM
TO
DAYS
MINUS
PERIOD
SICK DAYS
X
OF PAY
=
SICK PAY
-
X
=
-
X
=
-
X
=
-
X
=
-
X
=
-
X
=
-
X
=
-
X
=
-
X
=
TOTAL SICK PAY FOR YEAR
This is to certify that the payment(s) set forth above meet all three criteria in N.J.A.C. 18:35-2.3
__________________________________________________
Authorized Signature of Employer
__________________________________________________
Title
Date

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