Request For Irs To Figure Taxable Part Of Annuity - Department Of The Treasury Page 3
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4Tax Information Sheet -- Computation of Exclusion for Annuitant Under Section 72
Retired Annuitants: Complete and send in sections 1, 2, and 4 with your request.
Survivors of Deceased Employees or Retirees: Complete and send in sections 1, 3, and 4 with your
request.
Section 1. General Information for All Requests
A. Name of retiree, deceased employee, or deceased retiree
B. Name of taxpayer, if different from name above
C. Address
D. Daytime phone number
(
)
E. Organization providing annuity or pension
F. Annuity starting date
> month
day
year
G. Total taxed contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . > $
H. Taxed contributions after June 1986 * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . > $
* Employees in many retirement systems stopped paying taxes on contributions before July 1, 1986.
Does this statement apply to this annuity contract? Yes
No
If no, and if you cannot furnish the amount for item H, please indicate that you are electing, under
section 1.72-9 of the Federal Income Tax Regulations, to treat the entire cost of the contract as a post-
June 1986 cost. (Making this election tells IRS what annuity tables to use to figure the taxable part of
your annuity.)
I. Was the employee (or retiree) a nonresident alien at any time during his or her employment on which
the annuity is figured? No
Yes
If yes, please explain:
J. Is the annuity for life or for a specified period? Please explain:
K. Is there a feature which guarantees that a certain minimum amount will be paid under the contract,
even if the annuitant(s) should die before that amount has been paid?
No
Yes
If yes,
how much is guaranteed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . > $
L. Is the annuity a disability retirement annuity? No
Yes
If yes, when would you** have been
eligible for retirement if you had not been disabled? > month
day
year
M. Did you** elect to receive a modified annuity in order to receive a lump sum payment or other
benefit?
No
Yes
If yes, please indicate:
(I) Date you** made election
> month
day
year
(ii) Date of payment(s) > month
day
year
Type of payment(s) >
Amount . . . . . . . . . . > $
(iii) Annuity rate before election . . . . . . . . . . . . . . . . . . . . .
>
(iv) Annuity rate after election . . . . . . . . . . . . . . . . . . . . . . .
>
(v) Amount, deposit or redeposit of contributions you** were deemed to have made > $
N. Have you filed your return for the year for which your are making this request?
No
Yes
O. Have you requested an extension of time to file your return?
No
Yes
If yes, what
is the extension date?
> month
day
year
** If you are a survivor of a deceased employee or retiree, please answer questions L and M based on
what the deceased person did in relation to the annuity contract.
Are you:
The retired annuitant? If yes, go to Section 2.
A survivor of a deceased employee or retiree? If yes, skip to Section 3.
Page 3 of 4
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