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Get Also Enter This Date In The Space Provided On The Physician's Statement Below - Tax Ny

Number For limits on exclusion, see instructions on back. Employer s name (also give payer s name, if other than employer) Date you retired (if after December 31, 1976). Also enter this date in the space provided on the Physician s statement below. Date of retirement Yourself Date of retirement Spouse Which column(s) to fill in Use Column A to enter your disability income amounts. If you are married and your spouse also received disability income, enter your spouse s amounts i.

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