skip navigation

Search Help
Navigation Help

Topic Index
ABCDEFGHI
JKLMNOPQR
STUVWXYZ#

FAQs
Forms
Publications
Tax Topics

Comments
About Tax Map

IRS.gov Website
Instructions for Schedule R (Form 1040A or 1040)
taxmap/instr/i1040sr-003.htm#TXMP548c3945

Instructions for Physician's Statement(p4)

rule
taxmap/instr/i1040sr-003.htm#TXMP04760263

Taxpayer(p4)

rule
If you retired after 1976, enter the date you retired in the space provided on the statement below.
taxmap/instr/i1040sr-003.htm#TXMP64b47400

Physician(p4)

rule
A person is permanently and totally disabled if both of the following apply.
  1. He or she cannot engage in any substantial gainful activity because of a physical or mental condition.
  2. A physician determines that the disability has lasted or can be expected to last continuously for at least a year or can lead to death.

Physician's Statement

 I certify that                                                                                          
   Name of disabled person 
was permanently and totally disabled on January 1, 1976, or January 1, 1977, or was permanently and totally disabled on the
date he or she retired. If retired after 1976, enter the date retired.  ▸                              
Physician: Sign your name on either line A or B below.
AThe disability has lasted or can be expected to last continuously for at least a year
   Physician's signatureDate
BThere is no reasonable probability that the disabled condition will ever improve
   Physician's signatureDate
Physician's name Physician's address