8915 Qualified Hurricane Retirement Plan Distributions and Re

Form

8915

OMB No. 1545-0074

Qualified Hurricane Retirement
Plan Distributions and Repayments

Department of the Treasury
Internal Revenue Service

©

2008

Attachment
Sequence No.

Attach to Form 1040, Form 1040A, or Form 1040NR.

Name. If married, file a separate form for each spouse required to file Form 8915. See instructions.

Fill in Your Address Only
If You are Filing This
Form by Itself and Not
With Your Tax Return

©

156

Your social security number

Home address (number and street, or P.O. box if mail is not delivered to your home)

Apt. no.

City, town or post office, state, and ZIP code

Part I Qualified Hurricane Distributions From Retirement Plans (other than IRAs)
1

Enter the amount, if any, from your 2006 Form 8915, line 11, only if you did not check the box
on that line

1

2
3

2
3

Enter the amount, if any, from your 2007 Form 8915, line 8
Enter the amount, if any, from your 2007 Form 8915, line 3

4

Subtract line 3 from line 2. If zero or less, enter -0-

4

5

Enter the total amount of any repayments you made before filing your 2008 tax return. But do
not include repayments made later than the due date (including extensions) for that return. See
instructions

5

6

Add lines 4 and 5

6

7

Amount subject to tax in 2008. Subtract line 6 from line 1. If zero or less, enter -0-. Include
this amount in the total on Form 1040, line 16b; Form 1040A, line 12b; or Form 1040NR,
line 17b

7

Part II Qualified Hurricane Distributions From Traditional, SEP, SIMPLE, and Roth IRAs
8

Enter the amount, if any, from your 2006 Form 8915, line 26, only if you did not check the box
on that line

8

9
10

9
10

Enter the amount, if any, from your 2007 Form 8915, line 17
Enter the amount, if any, from your 2007 Form 8915, line 12

11

Subtract line 10 from line 9. If zero or less, enter -0-

11

12

Enter the total amount of any repayments you made before filing your 2008 tax return. But do
not include repayments made later than the due date (including extensions) for that return.
See instructions

12

13

Add lines 11 and 12

13

14

Amount subject to tax in 2008. Subtract line 13 from line 8. If zero or less, enter -0-. Include
this amount in the total on Form 1040, line 15b; Form 1040A, line 11b; or Form 1040NR,
line 16b

Sign Here Only If You
Are Filing This Form
by Itself and Not With
Your Tax Return

Paid
Preparer’s
Use Only

Preparer’s
signature

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14

Under penalties of perjury, I declare that I have examined this form, including accompanying attachments, and to the best of my
knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of
which preparer has any knowledge.

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Firm’s name (or yours
if self-employed),
address, and ZIP code

©

Your signature
Date

©

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

Date

Check if selfemployed ©
EIN

Preparer’s SSN or PTIN

©

Phone no.
Cat. No. 37726T

(

)
Form

8915

(2008)