Form I-026 - Schedule 2440w Disability Income Exclusion - Wisconsin Department Of Revenue - 2006
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SCHEDULE 2440W
Disability Income Exclusion
2006
Wisconsin Department of Revenue
(Applies Only to Disabled Retirees Under Age 65)
Enclose with Wisconsin
See instructions on back.
Form 1 or 1NPR
Name(s) shown on Form 1 or Form 1NPR
Your social security number
Date you retired
Employer’s name (also give payer’s name, if other than employer)
Yourself
Spouse
(1) YOURSELF
(2) SPOUSE
1 Fill in the amount of your disability pay which is included in your
federal adjusted gross income ................................................................................ 1
2 Excludable disability pay (see instructions):
(a) Multiply $100 by the number of weeks for which your disability payments
were at least $100. Fill in the total ..................................................................... 2a
(b) If you received disability payments of less than $100 for any week,
fill in the total amount you received for all such weeks ..................................... 2b
(c) If you received disability payments for less than a week, fill in the
smaller amount of either the amount you received or the highest
exclusion allowable for the period (see instructions) ......................................... 2c
(d) Add lines 2a, 2b, and 2c. Fill in the total ............................................................ 2d
3 Add amounts on line 2d, columns (1) and (2). Fill in the total in column (2) .............................................
3
4 Fill in the smaller of line 1 (total of columns (1) and (2)) or line 3 ..............................................................
4
5 Limit on exclusion (see instructions):
(a) Fill in adjusted gross income from line 37 of federal Form 1040,
line 21 of Form 1040A, or line 4 of Form 1040EZ ............................................. 5a
(b) Amount used to figure any exclusion decrease ................................................. 5b
$15,000.00
(c) Subtract line 5b from line 5a. If line 5b is more than line 5a, fill in -0- .................................................
5c
6 Subtract line 5c from line 4 and fill in on line 6. If line 5c is more than line 4, fill in -0-.
Full-year residents – This is your disability income exclusion. Fill in this amount on line 11
of Form 1. If filing Form 1NPR, see the instructions for line 1 or line 10 of Form 1NPR.
(Part-year residents – complete lines 7 and 8 below.) ...............................................................................
6
7 Part-year residents – Divide line 6 by the number of weeks you received disability payments ................
7
8 Part-year residents – Multiply line 7 by the number of weeks you were a Wisconsin resident and
received disability payments. This is your disability income exclusion. Fill in here and see the
instructions for line 1 or line 10 of Form 1NPR ...........................................................................................
8
9 If you filed a physician’s statement for this disability in an earlier year, please check this box.
You do not have to file another statement. If you have not, you must file a physician’s statement (see instructions).
Physician’s Statement of Permanent and Total Disability
Please complete and return to taxpayer.
Name of disabled taxpayer
Social security number
I certify that the taxpayer named above was (check only one box – please see instructions below)
(1)
Permanently and totally disabled on January 1, 1976, or January 1, 1977.
(2)
Permanently and totally disabled on the date he or she retired. Date retired
Physician’s name
Physician’s address
Physician’s signature
Date
Instructions for Statement
What is Permanent and Total Disability?
Taxpayer
Physician
A person is permanently and totally disabled when –
Please fill in your name and social
Box (1) applies to taxpayers who
• He or she cannot engage in any substantial gainful
security number. If you retired after
activity because of a physical or mental condition; and
retired before January 1, 1977.
December 31, 1976, fill in your
Box (2) applies to taxpayers who
• A physician determines that the disability (a) has
retirement date in the space after
retired after December 31, 1976.
lasted or can be expected to last continuously for at least
box (2).
a year; or (b) can be expected to lead to death.
I-026
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