| Taxpayer's name and annuity/pension type
for tax year |
Check if a public safety officer pension
?
Check if this is or was a disability pension ? | |||||
| Enter dates as MM/DD/YYYY | Age at annuity start | |||||
| Annuity start date | ||||||
|
||||||
| Earliest retirement age | Yr, Mo. | |||||
|
(N/A for annuity before 1998) ? | |||||
| Combined age for survivor annuity | Not used | |||||
Months received this year () |
|
|||||
| Gross distribution ( Check if RRB1099-R) |
|
|||||
| Total annuity contributions | ||||||
Annual cost of insurance to exclude |
||||||
| Exclusion months in 1st year | ||||||
| Total months to be excluded | ||||||
| Monthly exclusion | ||||||
| First year exclusion | ||||||
| Exclusion for remaining years | ||||||
| Final year exclusion | ||||||
|
or use the worksheet:
or use the worksheet:
|
|
| Schedule A - Medical Deductions |
| Medical and dental insurance - |
| Schedule A - Other Deductions |
| Unrecovered Investment in Pension - $ |
| Years of service | Retirement age | |
|---|---|---|
| Civil Service Retirement System (CSRS) | ||
| 5 | 62 | |
| 20 | 60 | |
| 201 | 50 | |
| 30 | 55 | |
| Federal Employees Retirement System (FERS) | ||
| 5 | 62 | |
| 10 | 55 | |
| 201 | 50 | |
| 251 | Any | |
| Railroad Retirement Board (RRB) | ||
| 5 after 1995 | 62 | |
| 10 | 62 | |
| 30 | 60 | |