Form D-2440 - Disability Income Exclusion - 2015
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Government of the
2015
D-2440 Disability
*152400110002*
District of Columbia
Income Exclusion
This is a FILL-IN format. Please do not handwrite
Vendor ID#0002
OFFICIAL USE ONLY
any data on this form other than your signature.
Name as shown on Form D-40
Your social security number
Personal information
Date of your birth (MMDDYY)
Date you retired (MMDDYY)
Name of your employer
Payor, if other than employer
Date of spouse’s/registered domestic
partner’s birth(MMDDYY)
Date retired (MMDDYY)
Name of employer
Payor, if other than employer
Yes
No
Have you filed a physician’s certification for this disability in previous years?
If yes, do not file another certification. If no, you must file the physician’s certification provided below.
Income
If married or registered domestic partners, use both columns.
Round cents to the nearest dollar. If amount is zero, leave the line blank.
You
Your spouse/registered domestic partner
$
.00
$
.00
1
1
Total amount of disability payments received in 2015
$
.00
$
.00
2
2
Multiply $100 by the number of weeks you received
disability payments in 2015. If you received pay for part
of a week, see Line 2 instructions on the back.
$
.00
$
.00
3
3
Enter Line 1 or Line 2 amount, whichever is less.
Total income
$
.00
4
4
Add the amounts for you and your spouse/registered domestic partner from Line 3.
Limitation on exclusion
$
.00
5
5
Federal adjusted gross income from Form D-40, Line 3.
$
.00
6
6
Taxable social security income from Form D-40, Line 9.
$
.00
7
7
Subtract Line 6 from Line 5.
– 1 5 0 0 0
.00
8
Amount used to reduce the excludable disability income.
$
.00
9
9
Subtract Line 8 from Line 7. If zero or a negative number, stop here. Do not file this form.
$
.00
10
10
Disability income payment excludable. Subtract Line 9 from Line 4.
Enter on D-40 Schedule I, Calculation B, Line 2 (see D-40 instructions). The exclusion may not exceed $5200 per disabled person.
Government of the
2015
Physician’s Certification of Permanent and Total Disability
District of Columbia
Name of disabled taxpayer
Social security number
MM
DD
YY
I certify that the above taxpayer was permanently and totally disabled when the taxpayer retired. (Enter retirement date.)
Physician’s first name, middle initial, last name
Physician’s address (number and street)
Suite number
City
State
Zip Code + 4
Physician’s phone number
Physician’s signature
Date
Attach to Form D-40. See instructions on back.
2015 D-2440 P1
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Revised 11/2015
Disability Income Exclusion
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