Form It-221 - Disability Income Exclusion - 2014

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New York State Department of Taxation and Finance
IT-221
Disability Income Exclusion
New York State
New York City
Yonkers
Submit this form with Form IT-201 or IT-203.
Name(s) as shown on your return
Social security number
For limits on exclusion, see instructions, Form IT-221-I.
Date you retired (if after December 31, 1976). Also enter this
Employer’s name
date in the space provided on the Physician’s statement on back.
(also give payer’s name, if other than employer)
Date of retirement
Yourself
Date of retirement
Your
Spouse
Mark an X in the box if you did not live with your spouse during any part of the tax year.
Which column(s) to fill in –
Use Column A to enter your disability income amounts. If you are married and your spouse also received
disability income, enter your spouse’s amounts in Column B. If you checked filing status , Married filing separate return, see instructions.
Column A (yourself)
Column B (your spouse)
1 Enter total disability pay you received during this tax year ...........
00
00
1
.
1
.
(see instructions)
Excludable disability pay
2 Multiply $100 by the number of weeks for which your disability
payments were at least $100. Enter total ...................................
00
00
.
.
2
2
3 If you received disability payments of less than $100 for any
week, enter the total amount you received for all such weeks ...
00
00
.
.
3
3
4 If you received disability payments for less than a week, enter
the smaller amount of either the amount you received or the
highest exclusion allowable for the period
.......
(see instructions)
00
00
.
.
4
4
5 Add lines 2, 3, and 4. Enter the total .............................................
00
00
.
.
5
5
6 Add amounts on line 5, columns A and B. Enter the total ..............................................................
00
6
.
(see instructions)
Limit on exclusion
7 Enter amount from Form IT-201, line 19, or
Form IT-203, line 19, Federal amount column ..........................................................................
00
7
.
8 Amount used to figure any exclusion decrease ............................................................................
.
8
15000
00
9 Subtract line 8 from line 7. If line 8 is larger than line 7, enter 0 ...................................................
00
.
9
10 Subtract line 9 from line 6. If line 9 is larger than line 6, stop;
you cannot claim any disability income exclusion ..................................................................... 10
00
.
11 Enter line 10 amount in Column A. This is your disability income
Column A (yourself)
Column B (your spouse)
exclusion. However, if both spouses received disability pay,
see instructions for proration. .................................................... 11
00
00
.
.
11
Transfer the total of columns A and B to Form IT-225, line 10, Total amount column
and enter subtraction modification S-124 in the Number column.
Statement of permanent and total disability
If you filed a Physician’s statement for this disability for tax year 1984, or you filed a Physician’s statement for tax
years after 1984 and your physician marked an X in box B on the Physician’s statement, and due to your continued
disabled condition you were unable to engage in any substantial gainful activity in this tax year, mark an X in this box . .........
If you marked the box above, you do not have to file another Physician’s statement for this tax year. If you did not mark the box
above, have your physician complete the Physician’s statement on the back of this form, and submit both front and back pages
with your return.
221001140094

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