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      Schedule                                                                                                               Enclosure 
04                                    Indiana Disability Retirement Deduction
05    IT-2440                                         Attach to Form IT-40 or Form IT-40PNR.                          Sequence No. 15
    State Form 46003                                                                                         2023
06    (R17 / 9-23)
07                Your Social                                                  Spouse’s Social 
08                Security Number     999              99       9999           Security Number           999    99    9999
09    Your first name                                           Initial  Last name
10
11                XXXXXXXXXXXXXXX                               X       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
12    If filing a joint return, spouse’s first name             Initial  Last name
13
14                XXXXXXXXXXXXXXX                               X       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
15 ►Enter the date you and/or your spouse retired.          ►Enter the employer’s name below or give payer’s name, if other than employer.
16             Yourself                                Spouse             Your Employer’s or Payer’s Name
17
18  99         99       9999          99               99       9999      XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
19  M M           D D   Y Y Y Y       M M              D D      Y Y Y Y
20 ►Your Daytime Telephone Number                                         Spouse’s Employer’s or Payer’s Name
21
22             9999999999                                                 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
23
           • To claim this deduction, you must complete lines 1 through 6 and enclose this schedule with your Indiana return.
24  Note   • Joint return filers use lines 1A and 3A for you and/or lines 1B and 3B for your spouse’s information.
25
26                                                                             Column A: Yours                Column B: Spouse’s
27
28 1. Enter total disability payments received during the year ______   1A     99999999999           .00     1B 99999999999.00
29
30 2.  Add lines 1A and 1B _____________________________________________________________                    2   99999999999.00
31 3.  Excess of disability payments over $100 per week 
32    (see line 3 instructions, Table A and the Worksheet)       _________  3A 99999999999           .00     3B 99999999999.00
33
34 4.  Excess of federal adjusted gross income over $15,000  
35    (over $7,500 if married filing separately - see instructions) _______________________________         4   99999999999.00
36
37 5.  Add lines 3A, 3B, and 4 __________________________________________________________                   5   99999999999.00
38 6. Line 2 minus line 5 (if less than zero, enter zero). This is your disability retirement deduction.  
39    Enter here and on Form IT-40, Schedule 2, under line 11, or on Form IT-40PNR, Schedule C, 
40    under line 11 ___________________________________________________________________   6                     99999999999.00
41
42                               Physician’s Statement of Permanent and Total Disability
43                                    Completed statement must be signed and dated by the physician.
44
45  Name of Disabled Individual                                                                                   Date you Retired
46  First Name                                         Initial  Last Name
47
48                                                                                                                M M D D         Y Y Y Y
49  Physician Information
50  First Name                                         Initial  Last Name
51
52  Address (Street Address, City, State and ZIP Code)
53
54
55 ►  I certify that the taxpayer named above is permanently and totally disabled (see instructions).
56
57    Physician’s Signature                                               Date
58     ___________________________________________________________________________________
59
60
61
62                                                    *24100000000*
63                                                              24100000000
64
65
66

                                             Line-by-Line Instructions

Do You Qualify for the Deduction?                                Table A - How to figure your weekly pay:
You may qualify for the deduction if you meet   both of the      If you were paid: Figure your weekly pay by:
following requirements:                                          Every 2 weeks ............. Divide your gross pay by 2
y You retired on disability before December 31 of the tax 
                                                                 Twice a month.............. Multiply your gross pay by 24 and
  year for which you are claiming the deduction; and
                                                                                   divide the result by 52
y You were permanently and totally disabled when you 
  retired.                                                       Once a month .............. Multiply your gross pay by 12 and
                                                                                   divide the result by 52
If you meet these requirements, you may be eligible to subtract 
                                                                 Any other way .............. Divide your gross yearly pay by 52
up to $5,200 a year of your disability payments from your gross 
income. The amount you subtract is limited to the amount of 
disability pay you actually received or $100 a week, whichever  Note: If you did not receive disability income for the whole 
is less, and may have to be reduced by part of your federal  year, use the actual amount of weeks/months.
adjusted gross income.
                                                                Example: Jim received disability income of $130 a week for 
Your spouse may also be eligible to subtract up to $5,200 of  six weeks. He should complete the worksheet below, entering 
disability payments if you file a joint return and your spouse  the $130 amount on line a.
meets all the above requirements.
                                                                  Worksheet - How to figure the excess over $100 for full 
Note: In  no  case  may  the  total  deduction  be  more  than    weeks:
$10,400 on a joint return.
                                                                 a. Weekly disability pay received ......... a  __________
                                                                 b.  Maximum weekly deduction ............ b - 100
General Instructions                                             c. Subtract line b from line a (If line b 
                                                                    is larger than line a, enter 0) ............ c  __________
Enter  your  name(s),  Social  Security  number(s)  and,  if     d. Number of full weeks for which you 
applicable, the date you retired.                                   received disability pay ..................... d  __________
                                                                 e. Multiply the amount on line c by line 
On a joint return, if both spouses qualify for the disability       d. Enter here and on line 3A or 3B 
retirement deduction, two Physician’s Statements must be            on the front of this schedule ............ e  __________
attached. Use only one Schedule IT-2440 to calculate the 
deduction.
                                                                Line 4 - The deduction is further reduced by the excess 
Line 1 - Enter the amount received during the taxable year      of the federal adjusted gross income (AGI) over $15,000 
through an accident and health plan for personal injuries or    ($7,500 if married filing separately).
sickness. Use line 1A for yourself and line 1B for your spouse.
                                                                a.  Federal AGI (from IT-40 line 1 or from 
Line 3 - The amount you can deduct is limited to the disability     IT-40PNR Schedule A, line 36A) ..... a   __________
income you received each week or $100 per week, whichever       b.  Income limit (see above) ................. b  -             
is less.                                                        c.  Subtract b from a (if b is larger 
                                                                    than a, enter 0). Enter here and on 
If you did not receive your disability pay each week, you will      line 4 on the front of this schedule ... c   __________
have to figure your weekly pay (see Table A).
                                                                Instructions for Physician’s Statement
                                                                A person is permanently and totally disabled when: 
                                                                y  He or she cannot engage in any substantial gainful 
                                                                   activity because of a physical or mental condition; and
                                                                y  A physician determines that the disability 
                                                                   (a) has lasted or can be expected to last continuously 
                                                                    for at least a year, or  
                                                                   (b) can be expected to result in death.           

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