New York Disability Income Exclusion

Disability Income Exclusion
Form IT-221 Disability Income Exclusion Tax Year 2023
IT-221

Department of Taxation and Finance

Disability Income Exclusion
New York State  •  New York City  • Yonkers
Submit this form with Form IT-201 or IT-203.
Name(s) as shown on your return	

Social Security number

For limits on exclusion, see instructions, Form IT-221-I.
Employer’s name

Date you retired (if after December 31, 1976). Also enter this
date in the space provided on the Physician’s statement on back.

Yourself
Your
Spouse

 (also give payer’s name, if other than employer)

	 Date of retirement
	 Date of retirement

Mark an X in the box if you did not live with your spouse during any part of the tax year.

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 in Column B. If you checked filing status , Married filing separate return, see instructions.
	

Column A (yourself)	

Column B (your spouse)

	 1	 Enter total disability pay you received during this tax year ............	 1	
.00	1	
	Excludable disability pay (see instructions)
	 2	 Multiply $100 by the number of weeks for which your disability
		  payments were at least $100. Enter total....................................	 2	
.00	
2	
	3	If you received disability payments of less than $100 for any
		  week, enter the total amount you received for all such weeks....	 3	
.00	
3	
	4	If you received disability payments for less than a week, enter
		  the smaller amount of either the amount you received or the
		  highest exclusion allowable for the period (see instructions) ........	 4	
.00	 4		
	5	Add lines 2, 3, and 4. Enter the total..............................................	 5	
.00	 5		
	6	Add amounts on line 5, columns A and B. Enter the total...............................................................	6	

.00
.00
.00
.00
.00
.00

Limit on exclusion (see instructions)
	 7	 Enter amount from Form IT-201, line 19, or
		  Form IT-203, line 19, Federal amount column ...........................................................................	 7	
.00
	8	Amount used to figure any exclusion decrease .............................................................................	 8	
15000.00
	9	Subtract line 8 from line 7. If line 8 is larger than line 7, enter 0 ....................................................	 9	
.00
	10	 Subtract line 9 from line 6. If line 9 is larger than line 6, stop;
		  you cannot claim any disability income exclusion ......................................................................	 10	
.00
	11	 Enter line 10 amount in Column A. This is your disability income
	
Column A (yourself)	
Column B (your spouse)
		  exclusion. However, if both spouses received disability pay,
		  see instructions for proration. .....................................................	 11	
.00	 11	
.00
Transfer the total of columns A and B to Form IT-225, line 10, Total amount column
and enter subtraction modification S-124 in the Number column.

Statement of permanent and total disability
If you filed a Physician’s statement for this disability for tax year 1984, or you filed a Physician’s statement for tax
years after 1984 and your physician marked an X in box B on the Physician’s statement, and due to your continued
	disabled condition you were unable to engage in any substantial gainful activity in this tax year, mark an X in this box ...........
If you marked the box above, you do not have to file another Physician’s statement for this tax year. If you did not mark the box
above, have your physician complete the Physician’s statement on the back of this form, and submit both front and back pages
with your return.
221001230094

IT-221 (2023) (back)

Physician’s statement

I certify that:
Name of patient

was permanently and totally disabled on January 1, 1976; or January 1, 1977; or was permanently and totally disabled on the date they
retired
Date retired if after December 31, 1976 (mmddyyyy)
Mark an X in box A or B below and sign. Mark only one box.

A	
	

The disability has lasted or can be expected
to last continuously for at least a year.............

Physician’s signature	

Date

B	
	

There is no reasonable probability that the
disabled condition will ever improve................ 	

Physician’s signature	

Date

	 Physician’s name (print or type)	

Physician’s address

Instructions for Physician’s statement
Taxpayer

Enter in the space provided the date you retired if after
December 31, 1976.
If required, your physician must complete the above statement.
File both front and back pages of this form with your tax return.
If both spouses take the exclusion, a Physician’s statement must
be completed for each spouse.
If you retired on disability before January 1, 1977, the
Physician’s statement must show that you were permanently
and totally disabled on January 1, 1976, or January 1, 1977.
If you retired on disability after 1976, the Physician’s statement
must show that you were permanently and totally disabled when
you retired.

221002230094

Physician

A person is permanently and totally disabled when they cannot
engage in any substantial gainful activity because of a physical
or mental condition, and a physician determines that the
disability:
–	 has lasted or can be expected to last continuously for at least
a year; or 
–	 can be expected to lead to death.
Complete the statement area above, sign the form, and return it
to the taxpayer to submit with their return.