Form 4973 - Michigan Pension Continuation Schedule - 2013
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Michigan Department of Treasury
4973 (Rev. 10-13)
2013 MICHIGAN Pension Continuation Schedule
Issued under authority of Public Act 281 of 1967.
NOTE: Complete this form if you have income from more than ten (10) retirement and pension benefits. This is a continuation
of Part 2, line 7 of the Michigan Pension Schedule (Form 4884). Attach this form to the MI-1040 and Form 4884.
1 4
0123456789
Type or print in blue or black ink. Print numbers like this:
- NOT like this:
Attachment 24
1. Filer’s First Name
M.I.
Last Name
2. Filer’s Social Security No. (Example: 123-45-6789)
If a Joint Return, Spouse’s First Name
M.I.
Last Name
3. Spouse’s Social Security No. (Example: 123-45-6789)
RETIREMENT AND PENSION BENEFITS CONTINUATION SCHEDULE FROM PART 2, LINE 7, FORM 4884
Do not enter Social Security, military or railroad retirement benefits here. Enter military pension benefits and railroad retirement
benefits on Schedule 1, line 11. Enter Social Security benefits on Schedule 1, line 14.
4. Retirement and pension benefits. List all additional benefits for filer and spouse (if filing jointly) including benefits from a deceased spouse.
B
A
D
F
C – Payer FEIN
E
Enter “X” for:
Enter “X” for
(from 1099-R)
Distribution
Pension Amount
Name of Payer
Deceased
(Example: 38-1234567)
Code
Included in AGI
Private or Public
Spouse
00
00
00
00
00
00
00
00
00
00
+
0000 2013 06 01 27 1
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