Schedule J (Form N-11/n-15/n-40) - Supplemental Annuities Schedule - 2015

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STATE OF HAWAII — DEPARTMENT OF TAXATION

SUPPLEMENTAL ANNUITIES SCHEDULE

SCHEDULE J

2015

Annuities, benefits under pension and profit-sharing plans, death

FORM N-11/N-15/N-40

benefits, and pensions in general.

(REV. 2015)

Attach to Form N-11, N-15, or N-40

Name(s) as shown on Form N-11, N-15, or N-40

Your Social Security Number or FEIN

PART I — COMPUTATION OF ANNUAL PENSION EXCLUSION

(Complete this Part only for the first year an annuity

is received. Keep a copy of the first year computations for your records because you will use information from

this Part every year you receive payments from your annuity.)

1. Annual annuity. ...........................................................................................................................................................

2. Multiple. (See Instructions.) ........................................................................................................................................

years

3. Total expected return. (Line 1 multiplied by line 2.) ....................................................................................................

4. Employee’s contributions:

a. Previously taxed contribution..............................................................................

Pretax contribution .............................................................................................

Total employee’s contributions. (Line 4a plus line 4b.) If there were no

employee contributions, see Instructions. ..........................................................

5. Employer’s contributions. If there were no employer contributions, enter zero on

line 5, skip lines 6-12, and enter zero on line 13. ......................................................

6. Total cost of annuity. (Line 4c plus line 5) ...................................................................................................................

7. Is this annuity received as part of an employer’s retirement plan because you retired or because you are a

Yes

beneficiary of someone who retired? If you checked No, skip lines 8 and 9 and enter zero on line 10. ....................

8. Portion of the total cost of the annuity attributable to employee contributions.

(Line 4c divided by line 6. Round to 2 decimal places.) .............................................................................................

9. Exclusion ratio. Portion of the total cost of the annuity attributable to employer contributions. (1.00 minus line 8) ..

10. Annual pension exclusion. (Line 9 multiplied by line 1.) .............................................................................................

11. Annual exclusion of the employee’s investment in the annuity contract. (Line 4a divided by the multiple on line 2.) .

PART II — COMPUTATION OF HAWAII TAXABLE ANNUITY (Complete for any year in which an annuity is received.)

12. Amount of annuity received this year. ........................................................................................................................

13. Annual pension exclusion. (From line 10 above, or from line 10 of your first Schedule J filed.) .................................

14. Line 12 minus line 13. ................................................................................................................................................

15. Enter total amount of annuity dividends received this year. .......................................................................................

16. Portion of total cost of annuity attributable to employee’s contribution. (See Instructions) ........................................

17. Taxable annuity dividends. (Line 15 multiplied by line 16.) .........................................................................................

18. Add lines 14 and 17. ..................................................................................................................................................

19. Annual recovery of employee’s investment. (From line 11 above, or from line 11 of your first Schedule J filed.) .....

20. Line 18 minus line 19. (For lump-sum distributions, see Instructions) ......................................................................

21. Death benefit exclusion for a beneficiary of a plan participant who died before August 21, 1996, if

applicable. (See Instructions) .....................................................................................................................................

22. Total taxable annuity. (Line 20 minus line 21.) Enter this amount on Form N-15, line 16, Column A, or on

Form N-40, line 8. ......................................................................................................................................................

PART III — COMPUTATION OF PENSION ADJUSTMENT TO HAWAII ADJUSTED GROSS INCOME (For Form N-11 Filers Only)

23. Enter the amount of your annuity received this year that is federally taxable. ............................................................

24. Pension adjustment to Hawaii Adjusted Gross Income. (Line 23 minus line 22)

Enter this amount on Form N-11, line 13 ...................................................................................................................

GENERAL INSTRUCTIONS

employee because of the employee’s death. Required distributions

received by pension plan participants who have reached age 70-1/2

This form is used to compute the taxable part of distributions from

and who are still employed by their employers also qualify as pensions.

pensions and other annuities received during the year. This form is also

Payments received because of separation of service before retirement

used for determining the taxable portion of lump-sum distributions from

do not qualify. Benefits incidental to a retirement plan received on or

qualified retirement plans for which the recipient uses Form N-152 and

after termination of employment because of death or disability qualify

makes the capital gain election or elects to use the 10-year averaging