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Iowa Department of Revenue
2012 IA 2440
Disability Income Exclusion
Applies to retirees under 65 who are disabled
Y
OUR NAME
SOCIAL SECURITY NUMBER
DATE OF BIRTH
SPOUSE’S NAME
SOCIAL SECURITY NUMBER
DATE OF BIRTH
DATE RETIRED:
EMPLOYER’S NAME (and Payer’s name if other than employer):
YOU
SPOUSE
COLUMN 1
COLUMN 2
Spouse - Combined
Taxpayer, Joint,
Only
Separate, or Single
1. TOTAL DISABILITY INCOME RECEIVED DURING THE TAX YEAR ............. 1. __________________________________
2. EXCLUDABLE DISABILITY PAY. See instructions.
a. Multiply $100 by the number of weeks your Disability Payments were
$100 or more. ENTER TOTAL ....................................................................... a. __________________________________
b. If you received Disability Payments of less than $100 for any week
ENTER THE TOTAL YOU RECEIVED FOR ALL SUCH WEEKS .............. b. __________________________________
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. See instructions ............. c. __________________________________
d. ADD Lines a, b, and c. ENTER TOTAL .......................................................... d. __________________________________
3. ADD amounts on line 2d column 1 and column 2. ENTER TOTAL ..................................................... 3. ________________
4. LIMIT ON EXCLUSION. See instructions.
a. ENTER YOUR FEDERAL ADJUSTED GROSS INCOME FROM FEDERAL 1040 ....................... a. ________________
$15,000
b. AMOUNT USED TO FIGURE EXCLUSION DECREASE .................................................................. b. ________________
c. SUBTRACT line 4b from line 4a. ENTER DIFFERENCE. If line 4b is greater than
line 4a, enter zero. ................................................................................................................................ c. ________________
5. SUBTRACT line 4c from line 3. ENTER DIFFERENCE here and on line 24 of IA1040 ................... 5.
Physician’s Statement of Permanent and Total Disability
NAME OF TAXPAYER WITH DISABILITY
SOCIAL SECURITY NO.
I certify that the taxpayer named above was permanently and totally disabled on the date he or she retired.
Date retired: ____________
PHYSICIAN’S NAME
PHYSICIAN’S ADDRESS
PHYSICIAN’S SIGNATURE
DATE
*1241127019999*
41-127a (08/10/12)