Form Ls Wks - Ohio Individual Income Tax Lump Sum Distribution Instructions Page 4
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4LS WKS
Ohio Lump Sum Distribution Credit Worksheet
Rev. 8/12
Page 4
Name:
Year:
Social Security number:
You may qualify for this credit even if you do not report in
If an individual receives a lump sum distribution as defi ned
by Internal Revenue Code section (I.R.C.) 402(e)(4)(D), the
your Ohio adjusted gross income (line 3 on Ohio form IT
taxpayer may be entitled to claim a lump sum distribution
1040) any portion of the lump sum distribution.
credit, which is in lieu of the $50 senior citizen credit.
Section I – Are you eligible to claim the lump sum distribution credit?
If the answers to questions 1 through 6 are all “yes,” then the distribution qualifi es for the lump sum distribution credit.
Yes
No
1. Was the lump sum recipient 65 or older at the end of the taxable year of the distribution? ....................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, below ......................2.
3. Was the distribution made from all of the employer’s qualifi ed plans of one kind in which the employee
had funds? ..............................................................................................................................................3.
4. Was the distribution for the balance of the full amount credited to the employee? .................................4.
5. Was the distribution paid within a single taxable year? ...........................................................................5.
6. Was the 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.
If you answered “No” to any one or more of the above questions, you do not qualify
for the lump sum distribution credit. Do not complete the rest of this page.
Section II – How to fi gure the lump sum distribution credit
Complete Section II only if you answered “Yes” to all six questions above.
1. Lump sum distribution recipient’s age at the end of the taxable year of the distribution (if
less than 65, stop here – you are not eligible for this credit) ........................................... 1.
2. Life expectancy from Table 2 (page 2) based on line 1 ......................................................... 2.
3. Multiply line 2 by $50. This amount is your lump sum distribution credit (limit $1,000). Enter
here and on the “lump sum distribution credit” line on Schedule B of Ohio form IT 1040 ..... 3. $
Note: You may claim the lump sum distribution credit only once. By claiming this credit, you are no longer eligible for the
annual senior citizen credit of $50 on any return to which you are a party.
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.
Note: Distributions from university retirement plans (see I.R.C. section 403(b)) and from govern-
ment-deferred compensation plans (see I.R.C. section 457) do not qualify for either the lump sum
retirement credit or the lump sum distribution credit because these plans are not described in I.R.C.
section 401(a).
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