Form 8930 Qualified Disaster Recovery Assistance Retirement Plan D

Form

8930

Department of the Treasury
Internal Revenue Service



Part I



2009
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 8930. See instructions.

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

OMB No. 1545-0074

Qualified Disaster Recovery Assistance
Retirement Plan Distributions and Repayments

164

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

Total Distributions From All Retirement Plans (Including IRAs)
Complete this part only if you have qualified disaster recovery assistance distributions for 2009 and the total of
your qualified disaster recovery assistance distributions for 2008, if any, was less than $100,000 (see
instructions).
Complete lines 1 through 5 of one column before going to
the next column
(a)
Total distributions
for 2009

1

2
3
4
5

6
7

Enter in columns (b) and (c) the amount, if any, from
your 2008 Form 8930, line 4, column (b). If this amount
is $100,000 or more, do not complete this part, you
have no qualified disaster recovery assistance
distributions for 2009
Distributions from retirement plans
Distributions from traditional, SEP, and SIMPLE IRAs
Distributions from Roth IRAs

9
10
11

12
13
14
15
16
17

18
19

(c)
Allocation of column (b)
(see instructions)

1
2
3
4

Totals. Add lines 1 through 4 in columns (a) and (b).
Complete column (c) only if line 5, column (b), is more
5
than $100,000
6
Subtract line 1 (in columns (b) and (c)) from $100,000
If you completed column (c), enter the excess of the amount on line 5, column (a), over the
amount on line 6, column (c). Otherwise, enter the excess of the amount on line 5, column (a),
over the sum of the amounts on lines 2 through 4 in column (b). Report these distributions under
the normal rules in accordance with the instructions for your tax return

Part II
8

(b)
Qualified distributions
(see instructions)

100,000

00

7

Qualified Disaster Recovery Assistance Distributions From Retirement Plans (Other Than IRAs)

Did you enter an amount on line 2, column (b)?
No. Skip lines 8 through 11, and go to line 12.
Yes. If you completed line 2, column (c), enter that amount. Otherwise, enter the amount
from line 2, column (b)
Enter the applicable cost of distributions, if any. See instructions
Subtract line 9 from line 8
If you elect NOT to spread the taxable amount over 3 years, check this box 
and enter the
amount from line 10. You must check this box if you check the box on line 26. Otherwise, divide
line 10 by 3.0
Enter the amount, if any, from your 2008 Form 8930, line 9. If you checked the box on that line,
enter -0Add lines 11 and 12
14
Enter the amount, if any, from your 2008 Form 8930, line 10
15
Enter the amount, if any, from your 2008 Form 8930, line 9
Subtract line 15 from line 14. If zero or less, enter -0Enter the total amount of any repayments you made before filing your 2009 tax return. But do
not include repayments made later than the due date (including extensions) for that return. See
instructions
Add lines 16 and 17
Amount subject to tax in 2009. Subtract line 18 from line 13. 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

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

Cat. No. 37744P

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9
10

11
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17
18

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Form

8930

(2009)

Form 8930 (2009)

Page

2

Before you begin: Complete Form 8606, Nondeductible IRAs, if required.

Part III

Qualified Disaster Recovery Assistance Distributions From Traditional, SEP, SIMPLE, and Roth IRAs

20

Did you enter an amount on line 3, column (b), or line 4, column (b)?
Yes. Go to line 21.
No. Skip lines 21 through 26, and go to line 27.

21

Did you receive a qualified disaster recovery assistance distribution from a traditional, SEP,
SIMPLE, or Roth IRA that is required to be reported on Form 8606?
Yes. Go to line 22.
No. Skip lines 22 through 23, and go to line 24.

22

Enter the amount, if any, from Form 8606, line 15b

22

23

Enter the amount, if any, from Form 8606, line 25b

23

24

If you completed line 3, column (c), enter that amount. Otherwise, enter the amount from line 3,
column (b). Do not include any amounts reported on Form 8606

24

25

Add lines 22, 23, and 24

25

26

If you elect NOT to spread the taxable amount over 3 years, check this box 
and enter the
amount from line 25. You must check this box if you checked the box on line 11. Otherwise, divide
line 25 by 3.0

26

Enter the amount, if any, from your 2008 Form 8930, line 17. If you checked the box on that line,
enter -0-

27

28

Add lines 26 and 27

28

29

Enter the amount, if any, from your 2008 Form 8930, line 18

29

30

Enter the amount, if any, from your 2008 Form 8930, line 17

30

31

Subtract line 30 from line 29. If zero or less, enter -0-

31

32

Enter the total amount of any repayments you made before filing your 2009 tax return. But do
not include repayments made later than the due date (including extensions) for that return.
See instructions

32

33

Add lines 31 and 32

33

34

Amount subject to tax in 2009. Subtract line 33 from line 28. 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

27

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



34

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.



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



Your signature
Date



Check if selfemployed 
EIN

Date
Preparer’s SSN or PTIN



Phone no.

(

)
Form

8930

(2009)