Enclosure
Indiana Disability Retirement Deduction
Schedule
2011
Sequence No. 15
IT-2440
Attach to Form IT-40, IT-40PNR or IT-40P
State Form 46003
(R5 / 9-11)
Your Social
Spouse’s Social
Security Number
Security Number
Your fi rst name
Initial
Last name
If fi ling a joint return, spouse’s fi rst name
Initial
Last name
►Enter the date you and/or your spouse retired.
►Enter the employer’s name below or give payer’s name, if other than employer.
Yourself
Spouse
Your Employer’s or Payer’s Name
M M
D D
Y Y Y Y
M M
D D
Y Y Y Y
►
Spouse’s Employer’s or Payer’s Name
Your Daytime Telephone Number
• To claim this deduction, you must complete lines 1 through 6 and enclose this schedule with your Indiana return.
Note
• Joint return fi lers use lines 1A and 3A for you and/or lines 1B and 3B for your spouse’s information.
Column A: Yours
Column B: Spouse’s
1.
Enter total disability payments received during the year ______
1A
1B
.00
.00
2.
Add lines 1A and 1B _____________________________________________________________
2
.00
3.
Excess of disability payments over $100 per week
(see line 3 instructions, Table A and the Worksheet) _________
3A
3B
.00
.00
4.
Excess of federal adjusted gross income over $15,000 (see line 4 instructions) _______________
4
.00
5.
Add lines 3A, 3B, and 4 __________________________________________________________
5
.00
6.
Line 2 minus line 5 (if less than zero, enter zero). This is your disability retirement deduction.
Enter here and on Form IT-40, Schedule 2, under line 11, or on Form IT-40PNR, Schedule C,
under line 11 ___________________________________________________________________
6
.00
Physician’s Statement of Permanent and Total Disability
To be completed by the physician
Name of Disabled Individual
Date you Retired
First Name
Initial
Last Name
M M
D D
Y Y Y Y
Physician Information
First Name
Initial
Last Name
Address
(Street Address, City, State and Zip Code)
► I certify that the taxpayer named above is permanently and totally disabled (see instructions).
Physician’s Signature
Date
___________________________________________________________________________________
24100000000