Schedule J (Form N-11/n-15/n-40) - Supplemental Annuities Schedule - 2015 Page 3
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SCHEDULE J (FORM N-11/N-15/N-40) INSTRUCTIONS
Your employer or the organization that pays you the benefits (the
Line 16. Portion of annuity attributable to employee’s contribution
plan administrator) should be able to tell you what your cost in the plan
— Enter the amount from line 8 or from line 8 of your first Schedule J
is.
filed, but if this annuity or distribution is not part of an employer’s pen-
sion plan or is received for a reason other than retirement, death, or
Line 4b. Employee’s contributions which were NOT previously
disability, enter 1.00 (100%).
taxed — The portion of the cost you paid for with money not previously
taxed may not be deductible, but is included as part of your cost.
Line 19. Annual recovery of employee’s investment. — Enter the
amount from line 11 or from line 11 of your first Schedule J filed. If the
Line 4c. Total employee’s contributions — Add the amounts on lines
beginning date of your annuity is a date other than the first day of the
4a and 4b. If the total is zero (i.e., there were no employee contribu-
year, the exclusion allowed for the first and last years will be the annual
tions), do not complete this form unless you are using this form to de-
amount multiplied by the ratio of months the annuity is received to the
termine the taxable amount of a lump-sum distribution to be reported
total number of months in the year.
on Form N-152. See “WHO SHOULD NOT USE THIS FORM” in the
general instructions. You do not have to complete the rest of this form.
If the employee’s total investment in the contract has been recovered
Enter the total amount received this year on Form N-15, line 16, Col-
and the annuity starting date is after 1986, do not include any amount
umn A. If there were no employee contributions and the payments
on this line for the recovery of the employee’s investment in the con-
received do not qualify as a pension, the entire amount received is tax-
tract.
able. Enter the total amount received on Form N-15, line 16, Column
Line 20. Taxable annuity or distribution before adjustment for the
A. If you are filing Form N-11, the taxable amount should have already
death benefit exclusion — If you are using this form to determine
been included in the amount reported as federal adjusted gross income
the taxable amount of a lump-sum distribution to be reported on Form
on line 7.
N-152, enter this amount on Part III, line 14 of Form N-152. You do not
Line 5. Employer’s contributions — Enter the amount paid by the
have to complete the rest of this form.
employer for the contract. If there were no employer contributions, en-
Line 21. Death benefit exclusion — Note: The employer-provided
ter zero on line 5, skip lines 6 through 12, enter zero on line 13, and
death benefit exclusion is repealed with respect to decedents dying
continue on line 14. Check with your employer or plan administrator for
after August 20, 1996.
the amounts.
If applicable, enter the amount from line 12 (Annual death benefit
Line 11. Annual exclusion of the employee’s previously taxed in-
exclusion for a beneficiary of a plan participant who died before August
vestment in the annuity contract — Divide the amount on line 4a by
21, 1996, if applicable) of your first Schedule J filed.
the multiple on line 2. This is the portion of your cost which is excluded
from taxation each year. The tax-free part remains the same even if the
Line 22. Total taxable annuity — Subtract the amount on line 21 from
total payment increases or you outlive the life expectancy factor used. If
the amount on line 20. Enter the result on Form N-15, line 16, Column
your annuity starting date is after 1986, however, the tax-free part can-
A, or on Form N-40, line 8.
not exceed the unrecovered cost of the contract.
PART III — COMPUTATION OF PENSION ADJUSTMENT
PART II — COMPUTATION OF HAWAII TAXABLE ANNUITY
TO HAWAII ADJUSTED GROSS INCOME
— Use this part
—
Use this Part to compute the taxable portion of pension and annuity
to compute the amount included in the federal adjusted gross income,
payments you received this year.
Form N-11, line 7, that is NOT taxable for Hawaii.
Line 13. Annual pension exclusion — Enter the amount from line 10
Line 23. Federal taxable amount — Enter the amount attributable
or from line 10 of your first Schedule J filed. If the beginning date of
to the taxable portion of this contract that is included in your federal
your annuity is a date other than the first day of the year, however, the
adjusted gross income.
exclusion allowed for the first and last years will be the annual pension
Line 24. Pension adjustment to Hawaii adjusted gross income —
exclusion multiplied by the ratio of months the annuity is received to the
Subtract the amount on line 22 from the amount on line 23. This is the
total number of months in the year.
amount that is NOT taxed by Hawaii. Enter the result on Form N-11,
Line 15. Amount of annuity dividends received this year — Enter
line 13.
the amount of any variable or indefinite amounts you received from
your pension or annuity this year in excess of the fixed, definite amount
shown on line 1 or on line 1 of your first Schedule J filed.
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