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   Schedule                                                                                                               Enclosure 
                                   Indiana Disability Retirement Deduction
   IT-2440                                         Attach to Form IT-40 or Form IT-40PNR.                          Sequence No. 15
 State Form 46003                                                                                         2023
   (R17 / 9-23)
               Your Social                                                  Spouse’s Social 
               Security Number                                              Security Number
   Your first name                                           Initial  Last name

   If filing a joint return, spouse’s first 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
►Your Daytime Telephone Number                                         Spouse’s Employer’s or Payer’s Name

        • To claim this deduction, you must complete lines 1 through 6 and enclose this schedule with your Indiana return.
 Note   • Joint return filers 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                           .00     1B                   .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                       .00     3B                   .00
4.  Excess of federal adjusted gross income over $15,000  
   (over $7,500 if married filing separately - see 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
                                   Completed statement must be signed and dated 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*
                                                             24100000000

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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.

*24100000000*
24100000000

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