Form 1040a Or 1040(Draft) - Instructions For Schedule R - Credit For The Elderly Or The Disabled (2015) Page 5

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Credit Limit Worksheet—Line 21
Keep for Your Records
Use this worksheet to figure your credit limit.
1. Enter the amount from Form 1040A, line 30; or Form 1040, line 47 . . . . . . . . . . . . . . . . . . . . . 1.
2. Enter the amount from Form 1040A, line 31; or Form 1040, lines 48 and 49 . . . . . . . . . . . . . . 2.
DRAFT AS OF
3. Subtract line 2 from line 1. Enter this amount on Schedule R (Form 1040A or 1040),
line 21. But if zero or less, STOP, you cannot take this credit . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.
August 14, 2015
Instructions for Physician's Statement
Taxpayer
Physician
If you retired after 1976, enter the date you retired in
A person is permanently and totally disabled if both
the space provided on the statement below.
of the following apply.
1. He or she cannot engage in any substantial
gainful activity because of a physical or mental
condition.
2. A physician determines that the disability has
lasted or can be expected to last continuously for at
least a year or can lead to death.
Physician's Statement
Keep for Your Records
I certify that
Name of disabled person
was permanently and totally disabled on January 1, 1976, or January 1, 1977, or was permanently and totally
disabled on the date he or she retired. If retired after 1976, enter the date retired.
Physician: Sign your name on either line A or B below.
A The disability has lasted or can be expected to
last continuously for at least a year . . . . . . . . . . . . .
Physician's signature
Date
B There is no reasonable probability that the
disabled condition will ever improve . . . . . . . . . . .
Physician's signature
Date
Physician's name
Physician's address
R-4

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