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STATE OF HAWAII — DEPARTMENT OF TAXATION

SCHEDULE J SUPPLEMENTAL ANNUITIES SCHEDULE
FORM N-11/N-15/N-40 Annuities, benefits under pension and profit-sharing plans, death
(REV.benefits,2023 2023)and pensions in general.
Attach to Form N-11, N-15, or N-40
Name(s) as shown on Form N-11, N-15, or N-40 Your Social Security Number or FEIN

PART I — COMPUTATION OF ANNUAL PENSION EXCLUSION (Complete this part only for the first year an annuity
is received. Keep a copy of the first year computations for your records because you will use information from
this part every year you receive payments from your annuity.)
1. Annual annuity............................................................................................................................................................ 1
2. Multiple (see Instructions) .......................................................................................................................................... 2 X years
3. Total expected return (line 1 multiplied by line 2). ...................................................................................................... 3
4. Employee’s contributions:
a. Previously taxed contribution. ............................................................................ 4a
b. Pretax contribution ............................................................................................. 4b
c. Total employee’s contributions (line 4a plus line 4b). If there were no
employee contributions, see Instructions. .......................................................... 4c
5. Employer’s contributions. If there were no employer contributions, enter zero on SCHJ_I 2023A 01 VID01
line 5, skip lines 6-9, and enter zero on lines 10 and 13. .......................................... 5
6. Total cost of annuity (line 4c plus line 5) .................................................................................................................... 6
7. Is this annuity received as part of an employer’s retirement plan because you retired or because you are a Yes No
beneficiary of someone who retired? If you checked No, skip lines 8 and 9 and enter zero on line 10. ................... 7
8. Portion of the total cost of the annuity attributable to employee contributions.
(Line 4c divided by line 6. Round to 2 decimal places.) ............................................................................................. 8
9. Exclusion ratio. Portion of the total cost of the annuity attributable to employer contributions (1.00 minus line 8) .... 9
10. Annual pension exclusion (line 9 multiplied by line 1) ................................................................................................ 10
11. Annual exclusion of the employee’s investment in the annuity contract (line 4a divided by the multiple on line 2) ... 11
PART II — COMPUTATION OF HAWAII TAXABLE ANNUITY (Complete for any year in which an annuity is received.)
12. Amount of annuity received this year. ........................................................................................................................ 12
13. Annual pension exclusion (from line 10 above, or from line 10 of your first Schedule J filed) ................................... 13
14. Line 12 minus line 13. ................................................................................................................................................ 14
15. Enter total amount of annuity dividends received this year. ....................................................................................... 15
16. Portion of total cost of annuity attributable to employee’s contribution (see Instructions) ......................................... 16
17. Taxable annuity dividends (line 15 multiplied by line 16) ........................................................................................... 17
18. Add lines 14 and 17. .................................................................................................................................................. 18
19. Annual recovery of employee’s investment (from line 11 above, or from line 11 of your first Schedule J filed) ......... 19
20. Line 18 minus line 19. (For lump-sum distributions, see Instructions) ...................................................................... 20
21. Death benefit exclusion for a beneficiary of a plan participant who died before August 21, 1996, if
applicable (see Instructions) ...................................................................................................................................... 21
22. Total taxable annuity (line 20 minus line 21). Enter this amount on Form N-15, line 16, Column A, or on
Form N-40, line 8. ...................................................................................................................................................... 22 00
PART III — COMPUTATION OF PENSION ADJUSTMENT TO HAWAII ADJUSTED GROSS INCOME (For Form N-11 Filers Only)
23. Enter the amount of your annuity received this year that is federally taxable. ........................................................... 23
24. Pension adjustment to Hawaii Adjusted Gross Income (line 23 minus line 22).
Enter this amount on Form N-11, line 13 ................................................................................................................... 24 00
made to a retired employee as well as payments made to the ben-
GENERAL INSTRUCTIONS eficiary of a retired employee because of the employee’s death.
Use this form to compute the taxable part of distributions you Required distributions received by pension plan participants who
received from pensions and other annuities during the year. This have reached age 70-1/2 and who are still employed by their em-
form is also used for determining the taxable portion of lump-sum ployers also qualify as pensions. Due to the changes made by the
distributions from qualified retirement plans for which the recipient SECURE Act, if your 70th birthday is July 1, 2019 or later, you do
uses Form N-152 and makes the capital gain election or elects to not have to take withdrawals until you reach age 72. See Publica -
use the 10-year averaging method. tions 575 and 590-B. Payments received because of separation
of service before retirement do not qualify. Benefits incidental to
To qualify as a pension, the payment must be received upon a retirement plan received on or after termination of employment
retirement from an employers’ retirement plan. It can be received because of death or disability qualify for the pension exclusion if the
in a lump-sum or in periodic payments. This includes payments other requirements for the exclusion are met.

ID NO 01 SCHEDULE J (FORM N-11/N-15/N-40)

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SCHEDULE J (FORM N-11/N-15/N-40) INSTRUCTIONS
PAGE 2 (REV. 2023)
The pension exclusion applies only to amounts attributable to in the amount reported as federal adjusted gross income on
employer contributions. Amounts attributable to employer contribu- line 7.
tions which already have been deducted under other provisions
cannot be deducted again. 3. A pension plan to which NO employee contributions were
made (i.e. the employer paid for the entire cost of the pension)
Note: Section 18-235-7-03(c), Hawaii Administrative Rules, clar- if distributions are made after retiring or after attaining the age
ifies that pension plan distributions received after 1997 are exempt of 70-1/2. Due to the changes made by the SECURE Act, if
from the Hawaii income tax when the distributions are attributable your 70th birthday is July 1, 2019 or later, you do not have to
to certain employer contributions. The purpose of the rule is to ex- take withdrawals until you reach age 72. See Publications 575
empt distributions attributable to employer contributions, notwith- and 590-B. The entire amount is NOT subject to Hawaii taxa -
standing the employer’s choice of entity for doing business (i.e., tion and need not be reported. If you are filing Form N-11, the
sole proprietorship, S corporations, partnerships, and limited liabil- amount reported as taxable for federal should be included on
ity companies). Form N-11, line 13.
WHO MUST USE THIS FORM 4. A pension plan to which NO employee contributions were
made (i.e. the employer paid for the entire cost of the pension)
You MUST use this form if you received payment from any of the if distributions are made for any reason other than retirement
following: or the attainment of age 70-1/2 (e.g., you quit, were laid off
or fired, the plan was terminated, etc.). Due to the changes
1. A privately purchased annuity. The portion of your cost includ- made by the SECURE Act, if your 70th birthday is July 1, 2019
ed in each distribution may be excluded. or later, you do not have to take withdrawals until you reach
2. A profit-sharing plan to which employee contributions were age 72. See Publications 575 and 590-B. The full amount re -
made. Only the increase in the value of the plan attributable ceived is taxable and must be reported on Form N-15, line
to your contributions is taxable. 16, Column A. If you are filing Form N-11, the taxable amount
should have already been included in the amount reported as
3. A death benefit as a beneficiary of a deceased employee. federal adjusted gross income on line 7.
4. A pension plan to which employee contributions were made 5. The state retirement system or any other public retirement
(i.e. both the employee and the employer contributed towards system. Distributions from a public retirement system are not
the cost of the pension). Only the increase in the value of the subject to Hawaii’s personal net income tax. However, dis-
plan attributable to your contributions is taxable. tributions attributable to voluntary contributions made under
5. A qualified retirement plan in the form of a lump-sum and you an elective right by an employee of a government employer
are using Form N-152 to make a capital gain election or to use are subject to Hawaii personal income tax (see sections 18-
the 10-year averaging method to report the lump-sum distri- 235-7-01 through 18-235-7-03, Hawaii Administrative Rules
bution. (HAR)). If voluntary contributions were made, use this form to
calculate the amount of the pension income subject to Hawaii
6. A hybrid plan which is partly pension and partly deferred com - personal income tax. If you are filing Form N-11, the amount
pensation, such as a 401(k) plan with a profit-sharing compo - reported as taxable pension for federal income tax purposes,
nent or employer matching program, an SEP plan with em- but excluded from Hawaii personal income tax, should be in-
ployer contributions as well as salary reduction option, or any cluded on Form N-11, line 13.
similar hybrid plan.
If you have received a lump-sum distribution, also see Form
If you did not contribute to the cost of your annuity that is not a N-152, Tax on Lump-Sum Distributions.
part of an employer’s pension plan or you recovered your entire
cost before July 1, 1989, under the prior three year recovery rule, See Administrative Rules section 18-235-7-01 through 18-235-7-
report your total annuity received this year on Form N-15, line 16, 03 for further information.
Column A. If you are filing Form N-11, the taxable amount should
have already been included in the amount reported as federal ad- LINE-BY-LINE INSTRUCTIONS
justed gross income on line 7. PART I — COMPUTATION OF THE ANNUAL PENSION
If you receive benefits from more than one plan, a separate EXCLUSION — Use this part to compute the amount of the
Schedule J must be completed for each plan. nontaxable portion of pension or annuity payments received each
year.
WHO SHOULD NOT USE THIS FORM
This part must be completed only in the first year a distribution is
DO NOT use this form if you received a payment from any of the received. The computations made in this part will not change from
following: year to year. Keep a copy of this part since you will need the infor -
mation each year a distribution is received to compute the taxable
1. An annuity you receive which is NOT part of your employer’s portion of the distribution.
pension plan AND to which no employee contributions were
made. The full amount received is taxable and must be re- Line 1. Annual annuity — Enter the amount you will receive each
ported on Form N-15, line 16, Column A. If you are filing Form year. If you received a distribution for only part of a year, report an
N-11, the taxable amount should have already been included amount that reflects what you would have received had distribu -
in the amount reported as federal adjusted gross income on tions been made for a 12 month period.
line 7.
Include on this line only amounts that are fixed and definite. Any
2. An annuity you receive which is NOT part of your employer’s indefinite or varying amounts should be included in Part II, line 15.
pension plan in which the cost to you was recovered before
July 1, 1989, under the three year recovery rule formerly per - If you are using this form to determine the taxable amount of a
mitted. The full amount received is taxable and must be re- lump-sum distribution to be reported on Form N-152, enter on line
ported on Form N-15, line 16, Column A. If you are filing Form 1 the total amount of the distribution. If you are electing to include
N-11, the taxable amount should have already been included in taxable income this year the net unrealized appreciation (NUA)
of your employer’s securities received as part of the distribution,

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SCHEDULE J (FORM N-11/N-15/N-40) INSTRUCTIONS
(REV. 2023) PAGE 3
include on this line the appropriate amount from the box which is PART II — COMPUTATION OF HAWAII TAXABLE ANNUITY
your NUA in employer’s securities on federal Form 1099-R. — Use this Part to compute the taxable portion of pension and annuity
Line 2. Multiple — Enter the multiple used for federal purposes to payments you received this year.
determine the expected return on the contract. This number rep- Line 13. Annual pension exclusion — Enter the amount from
resents the expected number of years that the annuity will be paid line 10 or from line 10 of your first Schedule J filed. If the beginning
based on your age and other factors. See the discussion regarding date of your annuity is a date other than the first day of the year,
Expected Return and actuarial tables in Internal Revenue Service however, the exclusion allowed for the first and last years will be
Publication 939. the annual pension exclusion multiplied by the ratio of months the
If you are using this form to determine the taxable amount of a annuity is received to the total number of months in the year.
lump-sum distribution to be reported on Form N-152, enter “1” on Line 15. Amount of annuity dividends received this year — En-
this line. ter the amount of any variable or indefinite amounts you received
Line 4a. Employee’s contributions which were previously from your pension or annuity this year in excess of the fixed, defi-
taxed — This includes premiums, contributions, or other amounts nite amount shown on line 1 or on line 1 of your first Schedule J
paid including amounts your employer contributed if you were re- filed.
quired to include these amounts in income. Line 16. Portion of annuity attributable to employee’s contri-
Do NOT include amounts paid for health and accident benefits or bution — Enter the amount from line 8 or from line 8 of your first
deductible voluntary employee contributions. Also do NOT include Schedule J filed, but if this annuity or distribution is not part of an
any refunded premiums, rebates, dividends, or unrepaid loans (any employer’s pension plan or is received for a reason other than re-
of which were not included in your income) that you received be- tirement, death, or disability, enter 1.00 (100%).
fore the later of the annuity starting date or the date on which you Line 19. Annual recovery of employee’s investment. — Enter
received your first payment. Finally, do NOT include any additional the amount from line 11 or from line 11 of your first Schedule J filed.
premiums paid for double indemnity or disability benefits and any If the beginning date of your annuity is a date other than the first
other amounts received under the contract or plan before the later day of the year, the exclusion allowed for the first and last years will
of the above dates that you did not have to include in your income. be the annual amount multiplied by the ratio of months the annuity
Your employer or the organization that pays you the benefits (the is received to the total number of months in the year.
plan administrator) should be able to tell you what your cost in the If the employee’s total investment in the contract has been recov-
plan is. ered and the annuity starting date is after 1986, do not include any
Line 4b. Employee’s contributions which were NOT previously amount on this line for the recovery of the employee’s investment
taxed — The portion of the cost you paid for with money not previ- in the contract.
ously taxed may not be deductible, but is included as part of your Line 20. Taxable annuity or distribution before adjustment for
cost. the death benefit exclusion — If you are using this form to de-
Line 4c. Total employee’s contributions — Add the amounts on termine the taxable amount of a lump-sum distribution to be re-
lines 4a and 4b. If the total is zero (i.e., there were no employee ported on Form N-152, enter this amount on Part III, line 14 of Form
contributions), do not complete this form unless you are using this N-152. You do not have to complete the rest of this form.
form to determine the taxable amount of a lump-sum distribution to Line 21. Death benefit exclusion — Note: The employer-provid-
be reported on Form N-152. See “WHO SHOULD NOT USE THIS ed death benefit exclusion is repealed with respect to decedents
FORM” in the general instructions. You do not have to complete the dying after August 20, 1996.
rest of this form. Enter the total amount received this year on Form
N-15, on line 16, Column A. If there were no employee contribu- If applicable, (and to the to the extent that the original death
tions and the payments received do not qualify as a pension, the benefit exclusion has not been exhausted), enter the annual death
entire amount received is taxable. Enter the total amount received benefit exclusion (including any prorated amount from a lump sum
on Form N-15, line 16, Column A. If you are filing Form N-11, the distribution) for a beneficiary of a plan participant who died before
taxable amount should have already been included in the amount August 21, 1996, as reported on your first Schedule J filed.
reported as federal adjusted gross income on line 7.
Line 22. Total taxable annuity — Subtract the amount on line 21
Line 5. Employer’s contributions — Enter the amount paid by from the amount on line 20. Enter the result on Form N-15, line 16,
the employer for the contract. If there were no employer contribu- Column A, or on Form N-40, on the other income line.
tions, enter zero on line 5, skip lines 6 through 12, enter zero on
line 13, and continue on line 14. Check with your employer or plan PART III — COMPUTATION OF PENSION ADJUSTMENT
administrator for the amounts. TO HAWAII ADJUSTED GROSS INCOME — Use this part to
compute the amount included in the federal adjusted gross income,
Line 10. Annual pension exclusion — If an annual death benefit
exclusion applies, subtract the amount shown in line 21 from the Form N-11, on line 7, that is NOT taxable for Hawaii.
pension exclusion to avoid a double exclusion (see section 18-235- Line 23. Federal taxable amount — Enter the amount attribut-
7-03, HAR). able to the taxable portion of this contract that is included in your
Line 11. Annual exclusion of the employee’s previously taxed federal adjusted gross income.
investment in the annuity contract — Divide the amount on line Line 24. Pension adjustment to Hawaii adjusted gross income
4a by the multiple on line 2. This is the portion of your cost which — Subtract the amount on line 22 from the amount on line 23. This
is excluded from taxation each year. The tax-free part remains the is the amount that is NOT taxed by Hawaii. Enter the result on Form
same even if the total payment increases or you outlive the life N-11, line 13.
expectancy factor used. If your annuity starting date is after 1986,
however, the tax-free part cannot exceed the unrecovered cost of
the contract.

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