Due to your continued disabled condition, you were unable to engage in any

substantial gainful activity in 2004, check this box 

(99)

Schedule 3 Department of the Treasury—Internal Revenue Service

Credit for the Elderly or the Disabled

for Form 1040A Filers (Form 1040A) 2004 OMB No. 1545-0085

Name(s) shown on Form 1040A Your social security number

You may be able to take this credit and reduce your tax if by the end of 2004:

or

In most cases, the IRS can figure the credit for you. See the instructions.

Part I If your filing status is:

1 You were 65 or older 1

Check the

box for your

filing status

and age You were under 65 and you retired on permanent

and total disability

2

2

3 Both spouses were 65 or older 3

4 Both spouses were under 65, but only one spouse

retired on permanent and total disability 4

5 Both spouses were under 65, and both retired on

permanent and total disability 5 Married filing

jointly 6 One spouse was 65 or older, and the other spouse

was under 65 and retired on permanent and total

disability 6

7 One spouse was 65 or older, and the other spouse

was under 65 and not retired on permanent and

total disability 7

8 You were 65 or older and you lived apart from

your spouse for all of 2004 8

Married filing

separately 9 You were under 65, you retired on permanent and

total disability, and you lived apart from your

spouse for all of 2004 9

If: 1 You filed a physician’s statement for this disability for 1983 or an earlier year,

or you filed or got a statement for tax years after 1983 and your physician signed

line B on the statement, and

Part II

Statement of

permanent

and total

disability

2

Complete this part

only if you checked

box 2, 4, 5, 6,

or 9 above.

For Paperwork Reduction Act Notice, see Form 1040A instructions. Schedule 3 (Form 1040A) 2004

● You were age 65 or older ● You were under age 65, you retired on permanent

and total disability, and you received taxable

disability income.

Single,

Head of household, or

Qualifying widow(er)

And by the end of 2004: Check only one box:

Cat. No. 12064K

Yes

No

Skip Part II and complete Part III on the back.

Complete Parts II and III.

Did you check

box 1, 3, 7, or

8?





● If you did not check this box, have your physician complete the statement on

page 4 of the instructions. You must keep the statement for your records.

● If you checked this box, you do not have to get another statement for 2004.

But you must also meet other tests. See the separate instructions for Schedule 3.

TIP
Schedule 3 (Form 1040A) 2004

10 If you checked (in Part I): Enter: Part III Box 1, 2, 4, or 7 $5,000

Figure your

credit

Box 3, 5, or 6 $7,500

10

11

● Box 6, add $5,000 to the taxable disability income of the spouse

who was under age 65. Enter the total.

11

If you completed line 11, enter the smaller of line 10 or line 11; all

others, enter the amount from line 10.

12

12

Enter the following pensions, annuities, or

disability income that you (and your spouse if

filing a joint return) received in 2004.

13

Nontaxable part of social security benefits

and

a

Nontaxable part of railroad retirement benefits

treated as social security (see the instructions). 13a

Nontaxable veterans’ pensions

and

b

13b

Add lines 13a and 13b. (Even though these

income items are not taxable, they must be

included here to figure your credit.) If you did not

receive any of the types of nontaxable income

listed on line 13a or 13b, enter -0- on line 13c.

c

13c

14 Enter the amount from Form 1040A, line 22. 14

15 If you checked (in Part I): Enter:

Box 1 or 2 $7,500

Box 3, 4, 5, 6, or 7 $10,000

Box 8 or 9 $5,000 15

Subtract line 15 from line 14. If zero or less,

enter -0-.

16

16

17 Enter one-half of line 16. 17

18 Add lines 13c and 17. 18

Subtract line 18 from line 12. If zero or less, stop; you cannot take

the credit. Otherwise, go to line 20.

19

19

20 Multiply line 19 by 15% (.15). 20

● Box 2, 4, or 9, enter your taxable disability income.

● Box 5, add your taxable disability income to your spouse’s taxable

disability income. Enter the total.

For more details on what to include on line 11, see

the instructions.

Did you check

box 2, 4, 5, 6,

or 9 in Part I?

You must complete line 11.

Enter the amount from line 10

on line 12 and go to line 13.

Yes

No 



Box 8 or 9 $3,750

Page 2

Schedule 3 (Form 1040A) 2004

Any other pension, annuity, or disability benefit

that is excluded from income under any other

provision of law (see the instructions).

If you checked (in Part I):

21

21

Credit for the elderly or the disabled. Enter the smaller of line 20

or line 21 here and on Form 1040A, line 30. 22

TIP

22

Enter the amount from Form 1040A, line 28, minus any amount on

Form 1040A, line 29.