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     2017                       FORM IRA                                                                                                                                                                Page 1
                                Delaware Special Tax Computation                                              DO NOT WRITE OR STAPLE IN THIS AREA
                     Individual Retirement Account Distribution

LAST NAME(S) AS SHOWN ON RETURN YOUR FIRST NAME                       SPOUSE’S FIRST NAME                                                                                    YOUR SOCIAL SECURITY NUMBER

PRESENT HOME ADDRESS                                                                                                                                                         SPOUSE’S SOCIAL SECURITY NUMBER

CITY                            STATE                        ZIP CODE                                                                                                  Column A                         Column B
                                                                                                                                                                       (Spouse if filing status 4 only) (All other filing statuses)

1.   Enter total IRA contributions allowed as a deduction for federal purposes, but disallowed for Delaware
     purposes for all taxable years.....................................................................................................................                                                                           1
2.   Enter total IRA contributions allowed as a deduction for federal purposes for all taxable
     years..........................................................................................................................................................                                                               2
3.   Enter total distributions of principle in all years for which a FORM IRA has not been (and will not be)
     filed............................................................................................................................................................                                                             3
4.   Subtract Line 3 from Line 2 and enter the difference here.  If Line 3 is greater than Line 2, enter “0"
     here and on Line 9 of this form .................................................................................................................                                                                             4

5.   Enter total IRA distribution from Box 2 of Form 1099 pertaining to this distribution...................................                                                                                                       5
6.   Divide Line 1 by Line 4.  Round to the nearest tenth of a percent.  (For example .7526 to .753).  If
     greater than 1.0, enter 1............................................................................................................................                                                                         6

7.   Multiply Line 5 by Line 6............................................................................................................................                                                                         7
8.   Add all distributions excluded in prior years where a Form IRA has been filed.  (Total of Lines 10 on all
     prior year Forms IRA)................................................................................................................................                                                                         8

9.   Subtract Line 8 from Line 1, and enter here (but not less than 0)..............................................................                                                                                               9
10. Enter the lesser of Line 7 or Line 9.  (This is the portion of IRA distribution to be excluded from
     Delaware Taxable Income)........................................................................................................................                                                                              10

11. Enter Delaware Taxable Income from Form 200-01, Line 5 or Form 200-02, Line 41...............................                                                                                                                  11

12. Subtract Line 10 from Line 11.  This is your Delaware Adjusted Taxable Income.....................................                                                                                                             12
13. Compute your adjusted Delaware tax liability using the tax table if Line 12 is under $60,000., or the tax
     rate schedule if Line 12 is $60,000 or over................................................................................................                                                                                   13

14. Enter the Delaware tax liability from Form 200-01, Line 8 or Form 200-02, Line 42..................................                                                                                                            14

15. Subtract Line 13 from Line 14.  This is your overpayment........................................................................                                                                                               15

16. Add Line 15, Columns A and B.  This is the amount to be refunded.........................................................                                                                                                      16
Under penalties of perjury, I declare thatI have examined this return, including accompanying schedules and statements, and believe it is true,
correct and complete.  If prepared by a person other than the taxpayer, his declaration is based on all information of which he has any knowledge.
Your Signature                  Date                                  Signature of Paid Preparer                                                                                    Date

Spouse's Signature (if filing joint or combined return) Date          Address

Home Phone                      Business Phone                        City                                                                                                      State        Zip

E-Mail Address                                                        EIN, SSN OR PTIN        Business Phone                                                                        E-Mail Address

                Mail completed form to:   Division of Revenue, P.O. Box 508, Wilmington, Delaware 19899-0508

                                                                                              *DF21016019999*
     (Rev. 04/2017)                                                                                                                                                    DF21016019999