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NY Form IT-221: Disability Income Exclusion Statement

New York taxpayers who retired on disability use IT-221 to exclude part of their disability pay from New York State, New York City and Yonkers income tax. Page 2 holds the physician's statement certifying the taxpayer was permanently and totally disabled on the retirement date, or on January 1, 1976 or 1977 for earlier retirees. The taxpayer files both pages with Form IT-201 or IT-203.

Who completes it

The taxpayer completes page 1 (retirement date, employer, disability pay and the exclusion calculation) and enters the retirement date on page 2. The physician names the patient, marks box A or box B, signs and dates, and prints their name and address.

Submitting and payment

How to submit it
The physician returns the completed statement to the taxpayer, who submits both pages of IT-221 with Form IT-201 or IT-203.
Who pays
IT-221 lists no fee or billing code for the physician's statement.

Good to know

  • Box A means the disability has lasted or can be expected to last continuously for at least a year; box B means there is no reasonable probability the condition will ever improve. Mark only one.
  • A new statement is not needed if a prior statement had box B marked, or one was filed for 1984, and the taxpayer still could not engage in substantial gainful activity this year.
  • If both spouses take the exclusion, a separate physician's statement must be completed for each spouse.
  • Permanent and total disability means the person cannot engage in any substantial gainful activity because of a physical or mental condition lasting at least a year or expected to lead to death.

Get the official form

Download the current version from the source each time; forms change without notice.

Disability Income Exclusion (with Physician's statement)

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Should I mark box A or box B on IT-221?

Mark box A if the disability has lasted, or can be expected to last, continuously for at least a year. Mark box B if there is no reasonable probability the condition will ever improve. Box B matters later: with a box B statement on file, the taxpayer does not need a new statement each year while the condition continues.

What date does the physician certify on IT-221?

For taxpayers who retired on disability after December 31, 1976, the statement certifies permanent and total disability on the date they retired, which the taxpayer enters on page 2. For those who retired before January 1, 1977, it must show disability on January 1, 1976 or January 1, 1977.

Does the physician send IT-221 to the Tax Department?

No. The instructions tell the physician to complete the statement, sign it and return it to the taxpayer. The taxpayer files the front and back pages with the return and carries the exclusion to Form IT-225 as subtraction modification S-124.