Form 4973 - Michigan Pension Continuation Schedule - 2014
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Michigan Department of Treasury
Issued under authority of Public Act 281 of 1967, as amended.
4973 (Rev. 06-14)
2014 MICHIGAN Pension Continuation Schedule
INSTRUCTIONS: Complete this form if you have income from more than ten (10) retirement and pension benefits. This is a
continuation of the Michigan Pension Schedule (Form 4884), Part 2, line 7. Do not enter Social Security, military or railroad
retirement benefits here (see Schedule 1).
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 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)
Retirement and pension benefits. List all additional benefits that apply for filer (and spouse if filing jointly) including benefits from a
4.
deceased spouse.
B
A
D
F
C – Payer FEIN
E
Enter “X” for:
Enter “X” for
Distribution
Pension Amount
(from 1099-R)
Deceased
Name of Payer
(Example: 38-1234567)
Code
Included in AGI
Private or Public
Spouse
00
00
00
00
00
00
00
00
00
00
You must also attach a completed MI-1040, Schedule 1 and Form 4884 when filing this form.
+
0000 2014 06 01 27 9
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