Form 4884 - Michigan Pension Schedule - 2014
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Michigan Department of Treasury
Attach to Form MI-1040 and Schedule 1.
4884 (Rev. 06-14), Page 1 of 2
Issued under authority of Public Act 281 of 1967, as amended.
2014 MICHIGAN Pension Schedule (Form 4884)
NOTE: 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 was born during the period January 1, 1946, through January 1, 1948, and reached age 67
on or before December 31, 2014, do not complete this form. Instead, complete Schedule 1, line 24.
1 4
0123456789
Attachment 23
Type or print in blue or black ink. Print numbers like this:
- NOT like this:
1. Filer’s First Name
M.I.
Last Name
2. Filer’s Full Social Security No. (Example: 123-45-6789)
If a Joint Return, Spouse’s First Name
M.I.
Last Name
3. Spouse’s Full Social Security No. (Example: 123-45-6789)
PART 1: FILER’S AGE
Failure to complete Part 1 will result in your pension subtraction being denied.
4. Primary Filer Year of Birth (ex. 19xx)
5. If a Joint Return, Spouse 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 Full 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 (see Schedule 1).
Retirement and pension benefits. List all that apply for filer (and spouse if filing jointly) including benefits from a deceased spouse.
7.
C – Payer FEIN
A
B
D
F
E
(from 1099-R)
Enter “X” for
Distribution
Pension Amount
Enter “X” for
Name of Payer
Deceased
(Example: 38-1234567)
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.
Continue on page 2. This form cannot be processed if page 2 is not completed and attached.
You must also attach a completed MI-1040 and Schedule 1 when filing Form 4884.
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