Fillable Form Ia 2440 - Disability Income Exclusion

Form Ia 2440 - Disability Income Exclusion - 2013

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Iowa Department of Revenue

2013 IA 2440

Disability Income Exclusion

Applies to retirees under 65 who are disabled

OUR NAME

SOCIAL SECURITY NUMBER

DATE OF BIRTH

SPOUSE’S NAME

SOCIAL SECURITY NUMBER

DATE OF BIRTH

DATE RETIRED:

EMPLOYER’S NAME (and Payer’s name if other than employer):

YOU

SPOUSE

COLUMN 1

COLUMN 2

Spouse - Combined

Taxpayer, Joint,

Only

Separate, or Single

1. TOTAL DISABILITY INCOME RECEIVED DURING THE TAX YEAR ............. 1. __________________________________

2. EXCLUDABLE DISABILITY PAY. See instructions.

a. Multiply $100 by the number of weeks your Disability Payments were

$100 or more. ENTER TOTAL ....................................................................... a. __________________________________

b. If you received Disability Payments of less than $100 for any week

ENTER THE TOTAL YOU RECEIVED FOR ALL SUCH WEEKS .............. b. __________________________________

c. If you received Disability Payments for a partial week ENTER THE

SMALLER OF EITHER THE AMOUNT YOU RECEIVED OR THE HIGHEST

EXCLUSION ALLOWABLE FOR THE PERIOD. See instructions ............. c. __________________________________

d. ADD Lines a, b, and c. ENTER TOTAL .......................................................... d. __________________________________

3. ADD amounts on line 2d column 1 and column 2. ENTER TOTAL ..................................................... 3. ________________

4. LIMIT ON EXCLUSION. See instructions.

a. ENTER YOUR FEDERAL ADJUSTED GROSS INCOME FROM FEDERAL 1040 ....................... a. ________________

$15,000

b. AMOUNT USED TO FIGURE EXCLUSION DECREASE .................................................................. b. ________________

c. SUBTRACT line 4b from line 4a. ENTER DIFFERENCE. If line 4b is greater than

line 4a, enter zero. ................................................................................................................................ c. ________________

5. SUBTRACT line 4c from line 3. ENTER DIFFERENCE here and on line 24 of IA1040 ................... 5.

Physician’s Statement of Permanent and Total Disability

NAME OF TAXPAYER WITH DISABILITY

SOCIAL SECURITY NO.

I certify that the taxpayer named above was permanently and totally disabled on the date he or she retired.

Date retired: ____________

PHYSICIAN’S NAME

PHYSICIAN’S ADDRESS

PHYSICIAN’S SIGNATURE

DATE

*1341127019999*

41-127a (07/18/13)