Reset Form

Michigan Department of Treasury                                            Issued under authority of Public Act 281 of 1967, as amended. 
4973 (Rev. 03-22) 

2022 MICHIGAN Pension Continuation Schedule 

INSTRUCTIONS: Complete this form if you have income from more than eight (8) retirement and pension benefits. This is a 
continuation of the Michigan Pension Schedule (Form 4884), Part 3, line 8. Do not enter Social Security, military or railroad 
retirement benefits here (see Schedule 1). 

Type or print in blue or black ink.                                                        Attachment 24 
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) 

4. Retirement and pension benefits. List all additional benefits 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 
                                                                           Name of Payer 
Private or Public Deceased       (Example: 38-1234567)    Code                             Included in AGI 
                   Spouse              (see instructions) 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 

                                                                                                                                               00 
You must also include a completed MI-1040, Schedule 1 and Form 4884 when filing this form. 

+ 0000 2022 06 01 27 2