Schedule 2440w - Disability Income Exclusion - 2012
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1
2SCHEDULE 2440W
Disability Income Exclusion
2012
Wisconsin Department of Revenue
(Applies Only to Disabled Retirees Under Age 65)
Enclose with Wisconsin
See instructions on back.
Form 1 or 1NPR
Legal 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 (see instructions) .......................................... 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 federal Form 1040, 1040A, or 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, 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 the person named below.
Name of disabled person
I certify that the person 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?
A person is permanently and totally disabled when –
Taxpayer
Physician
• He or she cannot engage in any substantial gainful
Please fill in your name. If you
Box (1) applies to taxpayers who
activity because of a physical or mental condition; and
retired after December 31, 1976, fill in
retired before January 1, 1977.
your retirement date in the space after
• A physician determines that the disability (a) has
Box (2) applies to taxpayers who
box (2).
lasted or can be expected to last continuously for at least
retired after December 31, 1976.
a year; or (b) can be expected to lead to death.
I-026
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