Instructions For Schedule R (Form 1040a Or 1040)

Instructions For Schedule R (Form 1040a Or 1040) - 2012 Page 4

Do not include on line 13b any pension, annuity,

resulting from active service in the armed forces of

or similar allowance for personal injuries or sickness

any country, or in the National Oceanic and Atmos-

pheric Administration or the Public Health Service.

Also, do not include a disability annuity payable un-

der section 808 of the Foreign Service Act of 1980.

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

Instructions For Schedule R (Form 1040a Or 1040) - 2012 Page 4