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Michigan Department of Treasury
4884 (Rev. 08-21), Page 1 of 2 Include with Form MI-1040 and Schedule 1.

2021 MICHIGAN Pension Schedule (Form 4884)
Generally, if the filer and spouse were born after 1945, STOP; you are not entitled to a retirement and pension benefits subtraction. For exceptions, refer to
the instructions and the questionnaire “Which Section of Form 4884 Should I Complete?” for additional assistance.
Failure to complete this form in its entirety will result in your pension subtraction being denied.
Issued under authority of Public Act 281 of 1967, as amended. Type or print in blue or black ink. Attachment 23
1. Filer’s First Name M.I. Last Name 2. Filer’s Full Social Security No. (Example: 123-45-6789)

If a Joint Return, Spouse’s First Name M.I. Last Name 3. Spouse’s Full Social Security No. (Example: 123-45-6789)

PART 1: FILING INFORMATION
4. Primary Filer Year of Birth (ex. 19xx) 5. If a Joint Return, Spouse Year of Birth (ex. 19xx)

6. Checkemployment.here if you were born after January 1, 1955, were retired as of January 1, 2013, and received retirement benefits from SSA exempt

PART 2: DECEASED SPOUSE INFORMATION
If you are receiving retirement and pension benefits from a deceased spouse, complete lines 7a through 7e.
7a. Deceased Spouse Name 7b. Deceased Spouse Full Social Security No. 7c. Deceased Spouse Year of Birth (ex. 19xx)

7d. Check here if your deceased spouse was born after 1952, was retired as of January 1, 2013, and received retirement benefits from
SSA exempt employment.

Surviving Spouse Election. Check here if you elect to subtract retirement and pension benefits based on the year of birth of your older
7e. deceased spouse. You must be the surviving spouse who (1) has reached age 67, (2) has not remarried, and (3) claimed a subtraction for
retirement and pension benefits on a return jointly filed with the decedent in the year they died. See instructions.
PART 3: RETIREMENT AND PENSION BENEFITS (see instructions)
Do not enter Social Security, military or railroad retirement benefits here (see Schedule 1).
8. Retirement and pension benefits. List all that apply for filer (and spouse if filing jointly) including benefits from a deceased spouse.
A B C D E F
Enter “X” for Enter “X” for Payer FEIN (from 1099-R) Distribution Pension Amount
Private or Public Deceased (Example: 38-1234567) Name of Payer
Spouse (see instructions) Code Included in AGI

00
Check here and complete the Michigan Pension Continuation Schedule (Form 4973) if you have more than eight sources of
Retirement and Pension Benefits.

Continue on page 2. This form cannot be processed if page 2 is not completed and included.
You must also include a completed MI-1040 and Schedule 1 when filing Form 4884.
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2021 Form 4884, Page 2 of 2                                                                 Filer’s Full Social Security Number (Example: 123-45-6789) 

PART 4: To determine which section below to complete, review the questionnaire: “Which Section of Form 4884 
Should I Complete?” in the MI-1040 book. Complete only one of the sections below. 

SECTION A: 

  9. Enter $54,404 if single or $108,808 if filing jointly  ...........................................................................               9.  00 
10.  Enter military retirement benefits due to service in the U.S. Armed Forces or Michigan National 
     Guard, or taxable railroad retirement benefits included in AGI from Schedule 1, line 11 ................                                         10. 00 

11.  Subtotal. Subtract line 10 from line 9. If line 10 is greater than line 9, enter “0”  ...............................                            11. 00 
12.  Enter total public retirement and pension benefits, including public benefits received from a 
     deceased spouse who died prior to 2021  .........................................................................................                12. 00 

13.  Subtotal. Subtract line 12 from line 11. If line 12 is greater than line 11, enter “0”  ...........................                              13. 00 
14.  Enter total private retirement and pension benefits, including private benefits received from a 
     deceased spouse who died prior to 2021  .........................................................................................                14. 00 

15.  Enter the smaller of lines 13 or 14  ....................................................................................................        15. 00 
16.  Total Retirement and Pension Benefits Subtraction.  Add lines 12 and 15. Carry this amount to 
     Schedule 1, line 25  ........................................................................................................................... 16. 00 
SECTION B: 
17.  Total Retirement and Pension Benefits Subtraction. Enter total retirement and pension
     benefits, including benefits received from a deceased spouse who died prior to 2021 (maximum
     $20,000 if single or $40,000 if filing jointly). If you checked box 22C and/or 22G on Schedule 1
     or have military or railroad retirement benefits reported on Schedule 1, line 11, see instructions. 
     Carry this amount to Schedule 1, line 25..........................................................................................               17. 00 

SECTION C: 
18.  Total Retirement and Pension Benefits Subtraction. If you checked box 22C and/or 22G on 
     Schedule 1 and the older of you or your spouse was born after January 1, 1955 but before 
     January 2, 1960, enter retirement and pension benefits you received, up to $15,000 per eligible 
     taxpayer. If you have military or railroad retirement benefits reported on Schedule 1, line 11, see 
     instructions. Carry this amount to Schedule 1, line 25  ......................................................................                   18. 00 

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