Form D-2440 - Attachment To Form D-40 - Disability Income Exclusion - 2000

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GOVERNMENT OF THE DISTRICT

D-2440

2000

ATTACH

OF COLUMBIA

OFFICE OF THE CHIEF FINANCIAL OFFICER

TO

Disability Income Exclusion

OFFICE OF TAX AND REVENUE

FORM D-40

(Applies only to disabled retirees under 65)

Tax Year: From_____________________ to ______________________

IMPORTANT: Please read the instructions on the other side before completing this form.

To claim a disability income exclusion in the District of Columbia, you must complete this form and attach it to Form D-40.

Name of taxpayer

Social Security Number

—

—

Date retired

Date of birth

Name of Employer

Payor, if other than employer

Yourself:

Spouse:

Have you filed a Physician’s Certification for this disability in previous years? YES

NO

Use Column A for husband and Column B for wife

If YES, you do not have to file another certification.

filing a joint return or filing separate returns on one

If NO, you must file the Physician’s Certification provided below.

combined form. All other filers use Column B only.

A

B

1. Total amount of disability payments received this year

2. Multiply $100 by the number of weeks for which disability payments were received this year

3. Enter Line 1 or Line 2, whichever is less

4. Total. Add Col. A and Col. B of Line 3

LIMITATION ON EXCLUSION

5. Federal adjusted gross income (from Form D-40, Line 1 Col. A plus Col. B) . . . . . . . . . . . . . .

6. Taxable social security income

(from Form D-40, Line 51, Col. A plus Col. B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Line 5 minus Line 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$15,000.00

8. Amount of income used to reduce disability income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9. Line 7 minus Line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10. Disability income exclusion (Line 4 minus Line 9). Enter here

and on Form D-40, Part II, Line 52. (If both spouses have disability income, see instructions.) . . . . . . . . . . . . . . . . . . . . .

Physician’s Certification of Permanent and Total Disability

Attach to Form D-40

Name of disabled taxpayer

Social Security Number

—

—

I certify that the above named taxpayer was permanently and totally disabled on the date the taxpayer retired (see instructions below).

Date Retired

Name of physician

Physician’s address

Telephone Number

Physician’s signature

Date

INSTRUCTIONS FOR PHYSICIAN’S CERTIFICATION

B. Definition of Permanent and Total Disability. Permanent and total disabili-

ty means that a taxpayer is unable to engage in any substantial gainful activity

due to a medically determined physical or mental impairment which can result in

death or which has lasted or can be expected to last for a continuous period of a

A. Date Permanently or Totally Disabled

year or more. The substantial gainful activity referred to is not limited to the activ-

Certify if taxpayer retired on or after January 1, 1977. The date entered by the

ity or comparable activity, in which the taxpayer engaged prior to retirement or

taxpayer should be the date on which the taxpayer ceased active employment

disability.

because of his or her disability.

(Rev. 10/00)