Form It-221 - Disability Income Exclusion - 2013 Page 2
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2IT-221 (2013) (back)
Physician’s statement
I certify that:
Name of patient
was permanently and totally disabled on January 1, 1976; or January 1, 1977; or was permanently and totally disabled on the date he
or she retired
Date retired if after December 31, 1976
(mm-dd-yyyy)
Mark an X in box A or B below and sign. Mark only one box.
Physician’s signature
Date
The disability has lasted or can be expected
A
to last continuously for at least a year ............
Physician’s signature
Date
There is no reasonable probability that the
B
disabled condition will ever improve ...............
Physician’s name
Physician’s address
(please print or type)
Instructions for Physician’s statement
Taxpayer
Physician
Enter in the space provided the date you retired if after
A person is permanently and totally disabled when he or she
December 31, 1976.
cannot engage in any substantial gainful activity because of a
physical or mental condition, and a physician determines that
If required, your physician must complete the above statement.
the disability:
Be sure to file both front and back pages of this form with your
– has lasted or can be expected to last continuously for at least
tax return.
a year; or
If both spouses take the exclusion, a Physician’s statement must
– can be expected to lead to death.
be completed for each spouse.
Complete the statement area above, sign the form, and return it
If you retired on disability before January 1, 1977, the
to the taxpayer to submit with his or her return.
Physician’s statement must show that you were permanently
and totally disabled on January 1, 1976, or January 1, 1977.
If you retired on disability after 1976, the Physician’s statement
must show that you were permanently and totally disabled when
you retired.
221002130094
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