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04 Schedule IT-2440                                  Indiana Department of Revenue                                              Enclosure 
   State Form 46003                                                                                                      Sequence No. 15
05 (R18 / 9-24)                         Indiana Disability Retirement Deduction                           2024
06                                               Enclose with Form IT-40 or Form IT-40PNR.
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 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
24 Note: y      To claim this deduction, you must complete lines 1 through 6 and enclose this schedule with your Indiana return.
25       y      Joint return filers use lines 1A and 3A for you and/or lines 1B and 3B for your spouse’s information.
26
27                                                                       Column A – Yours                    Column B – Spouse’s
28
29 1. Enter total disability payments received during the year ____   1A 99999999999.00                   1B   99999999999.00
30
31 2.  Add lines 1A and 1B _____________________________________________________________                     2 99999999999.00
32 3.  Excess of disability payments over $100 per week 
33    (see line 3 instructions, Table A and the worksheet)  _______   3A 99999999999.00                   3B   99999999999.00
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 Individual 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 Physician’s Signature                                                                          Date
57
58
59
60
61
62                                      *24100000000*
63                                                            24100000000
64
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66

                           Instructions for Indiana Disability Retirement Deduction

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 following  If you were paid:             Figure your weekly pay by:
requirements:                                                        Every 2 weeks ..............  Divide your gross pay by 2
y  You retired on disability before December 31 of the tax year      Twice a month ..............  Multiply your gross pay by 24 and 
   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 
up to $5,200 a year of your disability payments from your gross      Any other way ............... Divide your gross yearly pay by 52
income. The amount you subtract is limited to the amount of 
disability pay you actually received or $100 a week, whichever is    Note. If you did not receive disability income for the whole year, 
less, and may have to be reduced by part of your federal adjusted    use the actual amount of weeks/months.
gross income.
                                                                     Example. Jim received disability income of $130 a week for six 
Your spouse may also be eligible to subtract up to $5,200 of         weeks. He should complete the worksheet below, entering the 
disability payments if you file a joint return and your spouse meets $130 amount on line a.
all the above requirements.
                                                                     Worksheet – How to Figure the Excess Over $100 for Full Weeks
Note. In no case may the total deduction be more than $10,400        a.  Weekly disability pay received ...............a        ___________
on a joint return.                                                   b.  Maximum weekly deduction ...................b  - ___________100
                                                                     c.  Subtract line b from line a (If line b 
General Instructions                                                     is larger than line a, enter 0)................... c   ___________
                                                                     d.  Number of full weeks for which you 
Enter your name(s), Social Security number(s) and, if applicable,        received disability pay ............................d  ___________
the date you retired.                                                e.  Multiply the amount on line c by line d.  
                                                                         Enter here and on line 3A or 3B 
On a joint return, if both spouses qualify for the disability            on the front of this schedule ...................e     ___________
retirement deduction, two Physician’s Statements must be 
attached. Use only one Schedule IT-2440 to calculate the             Line 4. The deduction is further reduced by the excess of the 
deduction.                                                           federal adjusted gross income (AGI) over $15,000 ($7,500 if 
                                                                     married filing separately).
Line 1. Enter the amount received during the taxable year through 
an accident and health plan for personal injuries or sickness. Use   a.  Federal AGI (from IT-40 line 1 or from  
line 1A for yourself and line 1B for your spouse.                        IT-40PNR Schedule A, line 36A) ............a           ___________
                                                                     b.  Income limit (see above) ........................b  - ___________
Line 3 . The amount you can deduct is limited to the disability      c.  Subtract b from a (if b is larger 
income you received each week or $100 per week, whichever is             than a, enter 0). Enter here and on 
less.                                                                    line 4 on the front of this schedule.......... c       ___________

If you did not receive your disability pay each week, you will have  Instructions for Physician’s Statement
to figure your weekly pay (see Table A).                             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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