Form D-2440 - Disability Income Exclusion
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1
Government of the
2006
D-2440 Disability
*062400110000*
District of Columbia
Income Exclusion
Important:
Print in CAPITAL letters using black ink.
Leave lines blank that do not apply.
official use only
Name as shown on Form D-40
Your social security number
Personal information
Date of your birth (MMDDYY)
Date you retired (MMDDYY)
Name of your employer
Payor, if other than employer
Date of spouse’s birth(MMDDYY)
Date spouse retired (MMDDYY)
Name of spouse’s employer
Payor, if other than employer
yes
no
Have you filed a physician’s certification for this disability in previous years?
If yes, you do not have to file another certification. If no, you must file the physician’s certification provided below.
Income
If married, use both columns.
Round cents to the nearest dollar. If amount is zero, leave the line blank.
You
Your spouse
$
.00
$
.00
1
1
Total amount of disability payments received in 2006
$
.00
$
.00
2
2
Multiply $100 by the number of weeks you claimed
disability payments in 2006. If you received pay for part
of a week, see instructions on the back.
$
.00
$
.00
3
3
Enter Line 1 or Line 2 amount, whichever is less.
Total income
$ .00
4
4
Add the amounts for you and your spouse from Line 3.
Limitation on exclusion
$ .00
5
5
federal adjusted gross income from Form D-40, Line 3.
$ .00
6
6
Taxable social security income from Form D-40, Line 10.
$ .00
7
7
Subtract Line 6 from Line 5.
- 1 5 0 0 0.00
8
Amount used to reduce disability income.
$ .00
9
9
Subtract Line 8 from Line 7. If the result is zero or a negative amount, leave this line blank.
$ .00
10
10
Disability income exclusion Subtract Line 9 from Line 4.
Enter in D-40 Schedule I, Calculation B, Line 2 (see Form D-40 instructions). The exclusion may not exceed $5200.
Government of the
2006
Physician’s Certification of Permanent and Total Disability
District of Columbia
Name of disabled
Social security number
MM
DD
YY
I certify that the above taxpayer was permanently and totally disabled on the date the taxpayer retired. (Enter the date retired.)
Physician’s first name, middle initial, last name
Physician’s address (number and street)
Suite number
City
State
Zip Code + 4
Physician’s phone number
Physician’s signature
Date
Attach to Form D-40. See instructions on back.
2006 D-2440 P1
Revised 2/07
Disability Income Exclusion
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