Form Ia 2440 - Disability Income Exclusion - 2015
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2Iowa Department of Revenue
2015 IA 2440
https://tax.iowa.gov
Disability Income Exclusion
This form should only be completed by retirees under 65 who are disabled with a federal adjusted
gross income below $20,200 (or below $25,400 if filing married and both spouses are retired, under
65, and disabled).
Your Name
Spouse’s Name
Your Social Security Number
Spouse’s Social Security Number
Your Date of Birth (Month/Day/Year)
Spouse’s Date of Birth (Month/Day/Year)
Your Retirement Date
Spouse’s Retirement Date
Your Employer (and Payer’s name if other than
Spouse’s Employer (and Payer’s name if other than
employer)
employer)
Column B
Column A
Spouse
You
1.
Total disability income received during the tax year. ......................................... 1.
2.
Exclude disability pay. See instructions.
a. Multiply $100 by the number of weeks your disability payments were
$100 or more. Enter total. ...................................................................... 2a.
b. If you received disability payments of less than $100 for any week
enter the total you received for all such weeks. .................................... 2b.
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. ......................................................................... 2c.
d. Add lines a, b, and c. Enter total. .......................................................... 2d.
3.
Add amounts on line 2d column A and column B. Enter total. ...................................
3.
4.
Limit on exclusion. See instructions.
a. Enter your federal adjusted gross income from federal 1040. .....................
4a.
b. Amount used to figure exclusion decrease. .................................................. 4b.
$15,000
c. Subtract line 4b from line 4a. Enter difference. If line 4b is greater than line
4a, enter zero. ............................................................................................ 4c.
5.
Subtract line 4c from line 3. Enter difference here and on line 24 of IA 1040. ............
5.
Physician’s Statement of Permanent and Total Disability
Name of Taxpayer with Disability _____________________________________________________________
Physician’s Name
Physician’s Address
I certify that the taxpayer was permanently and totally disabled on the date he or she retired, as noted above.
Physician’s Signature
Date
41-127a (09/02/15)
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