Form 4884 - Michigan Pension Schedule - 2013
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Michigan Department of Treasury
Attach this form to the MI-1040.
4884 (Rev. 10-13), Page 1
Issued under authority of Public Act 281 of 1967.
2013 MICHIGAN Pension Schedule, Form 4884
NOTE: If you, and your spouse if filing a joint return, were born after December 31, 1952 and no pension benefits were received from a deceased
spouse, do not complete this form.
1 4
0123456789
Type or print in blue or black ink. Print numbers like this:
- NOT like this:
Attachment 23
2. Filer’s Social Security No. (Example: 123-45-6789)
1. Filer’s First Name
M.I.
Last Name
3. Spouse’s Social Security No. (Example: 123-45-6789)
If a Joint Return, Spouse’s First Name
M.I.
Last Name
If the filer and spouse (and deceased spouse from whom a surviving spouse is receiving benefits) were born after
December 31, 1952, STOP; you are not entitled to a pension subtraction. If the older of you or your spouse are age 67 in 2013
do not complete this form, instead complete Schedule 1, line 24.
PART 1: FILER’S AGE
Failure to complete Part 1 will result in your pension subtraction being denied.
5. If a Joint Return, Spouse Year of Birth (ex. 19xx)
4. Primary Filer Year of Birth (ex. 19xx)
If you are receiving retirement and pension benefits from a deceased spouse who was born prior to January 1, 1953,
complete lines 6a through 6c.
6a. Deceased Spouse Name
6b. Deceased Spouse Social Security No.
6c. Deceased Spouse Year of Birth (ex. 19xx)
PART 2: RETIREMENT AND PENSION BENEFITS (see instructions)
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.
7. Retirement and pension benefits. List all that apply for filer and spouse (if filing jointly) including benefits from a deceased spouse.
C – Payer FEIN
A
B
D
F
E
Enter “X” for
(from 1099-R)
Distribution
Enter “X” for
Pension Amount
Name of Payer
(Example: 38-1234567)
Deceased
Private or Public
Code
Included in AGI
Spouse
(see instructions)
00
00
00
00
00
00
00
00
00
00
Check this box and complete the Michigan Pension Continuation Schedule, Form 4973 if you have more than ten sources of
Retirement and Pension Benefits. (see instructions, page 16)
Continue on page 2. This form cannot be processed if page 2 is
not complete and attached.
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