2011 Instructions For Schedule R (Form 1040a Or 1040) (Draft) (Page 4 of 4) in pdf

2011 Instructions For Schedule R (Form 1040a Or 1040) (Draft) Page 4

Instructions for Physician’s Statement

Taxpayer

Physician

If you retired after 1976, enter the date you retired in the

A person is permanently and totally disabled if both of

space provided on the statement below.

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

Printed on recycled paper

2011 Instructions For Schedule R (Form 1040a Or 1040) (Draft) Page 4