Form 4973 - Michigan Pension Continuation Schedule - 2012
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Michigan Department of Treasury
4973 (08-12)
2012 MICHIGAN Pension Continuation Schedule
Issued under authority of Public Act 281 of 1967.
NOTE: Complete this form if you have income from more than six (6) retirement and pension benefits. This is a continuation
of Part 2, line 6 of the Michigan Pension Schedule (Form 4884). Attach this form to the MI-1040 and Form 4884.
1 4
0123456789
Type or print in blue or black ink. Print numbers like this:
- NOT like this:
Attachment 24
1. Filer’s First Name
M.I.
Last Name
2. Filer’s Social Security No. (Example: 123-45-6789)
If a Joint Return, Spouse’s First Name
M.I.
Last Name
3. Spouse’s Social Security No. (Example: 123-45-6789)
RETIREMENT AND PENSION BENEFITS CONTINUATION SCHEDULE FROM PART 2, LINE 6, FORM 4884
Do not enter Social Security, military or railroad retirement benefits here. Enter military pension benefits on Schedule 1, line 9.
Enter Social Security and railroad retirement benefits on Schedule 1, line 14.
4. Retirement and pension benefits. List all additional benefits that apply for Filer and Spouse (if filing jointly). Exclude any retirement and
pension benefits received from a deceased spouse.
A
C
D
B – Payer FEIN
Enter “X” for:
(from 1099-R) (Example: 38-1234567)
Name of Payer
Pension Amount
Private or Public
00
00
00
00
00
00
5. Total Continuation Retirement and Pension Benefits. Include this amount in the total on line 7,
page 1, of Form 4884, Michigan Pension Schedule ..........................................................................
5.
00
+
0000 2012 06 01 27 3
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