Form Ls Wks - Ohio Individual Income Tax Lump Sum Distribution Instructions Page 3
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LS WKS
Ohio Lump Sum Retirement Credit Worksheet
Rev. 8/12
Page 3
(1991 and subsequent taxable years)
Name:
Year:
Social Security number:
If an individual receives a lump sum distribution on account
Important: As a general rule, a taxpayer cannot claim the
of retirement, the taxpayer may be entitled to claim a lump
lump sum retirement credit for any subsequent lump sum
sum retirement income credit. For the individual to be eligible,
distribution that the taxpayer receives. Exception: If the
the distribution must be a qualifi ed lump sum as defi ned by
taxpayer has previously claimed a lump sum retirement credit
Internal Revenue Code (I.R.C.) section 402(e)(4)(D), and
and has a credit carryforward amount (see line 7e, below),
some portion of the lump sum distribution must be included
then upon receiving a subsequent lump sum distribution,
in Ohio adjusted gross income on line 3 of the taxpayer’s
the taxpayer may be entitled to an additional lump sum
income tax return, Ohio form IT 1040.
retirement credit. For more information, please contact us
at 1-800-282-1780.
Section I – Answer the following to determine if you are eligible to claim the lump sum retirement income credit
Yes
No
1. Was the lump sum distribution received on account of retirement? .........................................................1.
2. Was the lump sum distributed from a qualifi ed employee benefi t plan (such as pension, profi t-sharing,
stock bonus, Keogh, I.R.C. 401(k), STRS, PERS, SERS)? Important: See note on page 4 ..................2.
3. Was the lump sum distribution made from all of the employer’s qualifi ed plans of one kind in which the
employee had funds? ...............................................................................................................................3.
4. Was the lump sum distribution for the balance of the full amount credited to the employee? .................4.
5. Was the lump sum distribution paid within a single taxable year? ...........................................................5.
6. Was the lump sum distribution made because either (i) the employee died, quit, retired, was laid off or
was fi red or (ii) the taxpayer (if self-employed) became totally and permanently disabled? .......................6.
7. Is all or some portion of the lump sum distribution included in your Ohio adjusted gross income (line 3
on your Ohio income tax return, form IT 1040)? See note, below
..............................................................7.
If you answered “No” to any one or more of the above questions, do not complete
the rest of this page. You do not qualify for the lump sum retirement income credit.
Note: If for federal income tax purposes you used federal form 4972, Tax on Lump Sum Distribution, to report all or part of
the lump sum distribution, you must enter on the miscellaneous federal tax adjustments line on Schedule A of Ohio form IT
1040 the portion of the lump sum distribution taxed on federal form 4972.
Section II – How to fi gure the lump sum retirement credit
A. Lump sum retirement credit
1. Amount of retirement income (non-lump sum retirement income, if any, and lump sum
distribution) included in Ohio adjusted gross income (see line 3 on Ohio form IT 1040) 1. $
2. Lump sum distribution recipient’s age at the end of the taxable year of the distribution 2.
3. Life expectancy from Table 2 (page 2) based on age shown on line 2, above ............... 3.
4. Divide line 1 by line 3 ...................................................................................................... 4. $
5. Retirement income credit from Table 1 based on line 4 amount ..................................... 5. $
6. Lump sum retirement credit (line 3 times line 5). Enter amount here and on the “lump
sum retirement credit” line on Schedule B of form Ohio form IT 1040 ............................ 6. $
If the lump sum retirement credit exceeds the tax due after all other credits, complete line 7; if not, stop here.
7. Future retirement credit carryforward to subsequent taxable years
a) Line 6 amount ........................................................................................................... 7a. $
b) Ohio tax due after other credits .................................................................................. b. $
c) Unused amount (line 7a minus line 7b). If 0 or less, stop here. ...................................c. $
d) Line 3 minus 1 year .................................................................................................... d.
e) Future annual retirement credit carryforward amount (line 7c divided by line 7d) ...... e. $
If the lump sum retirement credit is used in its entirety, no lump sum retirement income credit or annual retirement income
credit can be claimed on any future return to which this taxpayer is a party [Ohio Revised Code section 5747.055(E)(2)].
Please enclose with your Ohio individual income tax return (Ohio form IT 1040) or with your amended Ohio individual income
tax return a copy of this worksheet and a copy of your form 1099R issued by the company or retirement plan that made the
lump sum distribution.
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