U.S. Individual Income Tax Return

PAGER/SGML
Page 1 of 4

Userid: ________
DTD INSTR04
Leadpct: -8% Pt. size: 9
Fileid: D:\Users\fmzhb\documents\2009 EPIC files\09I8930.SGM

Instructions for Form 8930 (2009)

❏ Draft
(Init. & date)

❏

Ok to Print

9:36 - 7-DEC-2009

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

2009

Department of the Treasury
Internal Revenue Service

Instructions for Form 8930
Qualified Disaster Recovery Assistance Retirement Plan
Distributions and Repayments
Section references are to the Internal
Revenue Code unless otherwise noted.

General Instructions
Purpose of Form
Use Form 8930 if you were adversely
affected by the Midwestern severe
storms, tornadoes, or flooding, and you
received a distribution that qualifies for
favorable tax treatment. See Table 1 on
page 4 for the Midwestern disaster areas.

Part I
Use Part I to figure your:
• Total distributions from all retirement
plans (including IRAs),
• Qualified distributions, and
• Distributions, other than qualified
disaster recovery assistance distributions.

Parts II and III
Use Parts II and III to:
• Report your qualified disaster recovery
assistance distributions,
• Report any repayments of qualified
disaster recovery assistance distributions,
and
• Figure the taxable amount, if any, of
your qualified disaster recovery
assistance distributions.
Note. Distributions from retirement plans
(other than IRAs) are reported in Part II
and distributions from IRAs are reported
in Part III.

Additional Information
See Pub. 4492-B, Information for Affected
Taxpayers in the Midwestern Disaster
Areas, for more details.

Who Must File
File Form 8930 if any of the following
apply.
• You received a qualified disaster
recovery assistance distribution from an
eligible retirement plan in 2009.
• You received a qualified disaster
recovery assistance distribution in 2008
that you are including in income in equal
amounts over 3 years.
• You made a repayment of a qualified
disaster recovery assistance distribution
in 2009.

When and Where To File
File Form 8930 with your 2009 Form
1040, 1040A, or 1040NR. If you are not
required to file an income tax return but
are required to file Form 8930, sign Form
8930 and send it to the Internal Revenue
Service at the same time and place you
would otherwise file Form 1040, 1040A,
or 1040NR.

How Is a Qualified Disaster
Recovery Assistance
Distribution Taxed?

plan in order to repay a loan can also be
designated as a qualified disaster
recovery assistance distribution. See
Distribution of plan loan offsets below.

Generally, a qualified disaster recovery
assistance distribution is included in your
income in equal amounts over 3 years.
However, if you elect, you can include the
entire distribution in your income in the
year of the distribution. If you received
more than one distribution during the
year, you must treat all distributions for
that year the same way. Any repayments
made before you file your return and by
the due date (including extensions)
reduce the amount of the distribution
included in your income.

Limit. The total of your qualified disaster
recovery assistance distributions for 2008
and 2009 from all plans is limited to
$100,000. If you have distributions in
excess of $100,000 from more than one
type of plan, such as a 401(k) plan and an
IRA, you can allocate the $100,000 limit
among the plans any way you choose.

Also, qualified disaster recovery
assistance distributions are not subject to
the additional 10% tax on early
distributions.

Qualified Disaster
Recovery Assistance
Distribution
A qualified disaster recovery assistance
distribution is any distribution you
received in 2009 from an eligible
retirement plan if both of the following
conditions are met.
1. Your main home was located in a
Midwestern disaster area on an
applicable disaster date (see Table 1 on
page 4).
2. You sustained an economic loss
because of the severe storms, tornadoes,
or flooding in the disaster area in which
your main home was located. Examples
of an economic loss include, but are not
limited to (a) loss, damage to, or
destruction of real or personal property
from fire, flooding, looting, vandalism,
theft, wind, or other cause; (b) loss
related to displacement from your home;
or (c) loss of livelihood due to temporary
or permanent layoffs.
If (1) and (2) apply, you can generally
designate any distribution (including
periodic payments and required minimum
distributions) from an eligible retirement
plan as a qualified disaster recovery
assistance distribution, regardless of
whether the distribution was made on
account of the severe storms, tornadoes,
or flooding in the Midwestern disaster
areas. Qualified disaster recovery
assistance distributions are permitted
without regard to your need or the actual
amount of your economic loss.
A reduction or offset in 2009 of your
account balance in an eligible retirement
Cat. No. 52382T

Eligible retirement plan. An eligible
retirement plan can be any of the
following.
• A qualified pension, profit-sharing, or
stock bonus plan (including a 401(k)
plan).
• A qualified annuity plan.
• A tax-sheltered annuity contract.
• A governmental section 457 deferred
compensation plan.
• A traditional, SEP, SIMPLE, or Roth
IRA.
Distribution of plan loan offsets. A
distribution of a plan loan offset is a
distribution that occurs when, under the
terms of a plan, the participant’s accrued
benefit is reduced (offset) in order to
repay a loan. A distribution of a plan loan
offset amount can occur for a variety of
reasons, such as when a participant
terminates employment or does not
comply with the terms of repayment. Plan
loan offsets are treated as actual
distributions and are reported on Form
1099-R, box 1.
Main home. Generally, your main home
is the home where you live most of the
time. A temporary absence due to special
circumstances, such as illness, education,
business, military service, evacuation, or
vacation, will not change your main home.
Additional tax. Qualified disaster
recovery assistance distributions are not
subject to the additional 10% tax (or the
25% additional tax for certain distributions
from SIMPLE IRAs) on early distributions
and are not required to be reported on
Form 5329. However, any distributions
you received in excess of the $100,000
qualified disaster recovery assistance
distribution limit may be subject to the
additional tax.
Note. If you choose to treat a distribution
as a qualified disaster recovery
assistance distribution, it is not eligible for
the 20% Capital Gain Election or the
10-Year Tax Option. For information on
those options, see the instructions for
Form 4972.

Page 2 of 4

Instructions for Form 8930 (2009)

9:36 - 7-DEC-2009

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Repayment of a Qualified
Disaster Recovery
Assistance Distribution
If you choose, you can generally repay
any portion of a qualified disaster
recovery assistance distribution that is
eligible for tax-free rollover treatment to
an eligible retirement plan. Also, you can
repay a qualified disaster recovery
assistance distribution made on account
of hardship from a retirement plan.
However, see Exceptions, below, for
qualified disaster recovery assistance
distributions you cannot repay.
You have 3 years from the day after
the date you received the distribution to
make a repayment. The amount of your
repayment cannot be more than the
amount of the original distribution.
Amounts that are repaid are treated as a
qualified rollover and are not included in
income. Also, for purposes of the
one-rollover-per-year limitation for IRAs, a
repayment of a qualified disaster recovery
assistance distribution to an IRA is not
considered a qualified rollover.
Include on Form 8930 any repayments
you make before filing your 2009 return.
Any repayments you make will reduce the
amount of qualified disaster recovery
assistance distributions reported on your
return for 2009. Do not include on your
2009 Form 8930 any repayments you
make later than the due date (including
extensions) for filing your 2009 return. If
you make a repayment in 2010 after you
file your 2009 return, the repayment will
reduce the amount of your qualified
disaster recovery assistance distributions
included in income on your 2010 return,
unless you are eligible to amend your
2009 return. See Amending Form 8930
on this page. Also, any excess
repayments you make for 2009 will be
carried forward to your 2010 return or, if
you choose, carried back to your 2008
return if applicable.
Also file Form 8606, Nondeductible
IRAs, to report any repayment of a
nondeductible contribution to a traditional
IRA on line 1 of Form 8606. If you make a
repayment of a previously deductible
contribution to a traditional IRA, do not file
Form 8606 solely because of such
repayment. If you make a repayment to a
Roth IRA, see Pub. 590 to figure your
basis.

Amending Form 8930
If, after filing your original return, you
make a repayment, the repayment may
reduce the amount of your qualified
disaster recovery assistance distributions
reported on that return. Depending on
when a repayment is made, you may
need to file an amended tax return to
refigure your taxable income.
If you make a repayment by the due
date of your original return (including
extensions), include the repayment on
your amended 2009 Form 8930.
If you make a repayment after the due
date of your original return (including
extensions), include the repayment on
your 2010 Form 8930. However, you can
file an amended Form 8930 for 2008 or
2009 if either of the following applies.
• You elected to include all of your
qualified disaster recovery assistance
distributions in income (instead of over 3
years) on your original return.
• The amount of the repayment exceeds
the amount of your qualified disaster
recovery assistance distributions that are
included in income for 2010 and you
choose to carry the excess back to your
2008 or 2009 tax return. See the example
below.
Example. You received a qualified
disaster recovery assistance distribution
in the amount of $90,000 on June 15,
2009. You choose to spread the $90,000
over 3 years ($30,000 in income for 2009,
2010, and 2011). On November 19, 2010,
you make a repayment of $45,000. For
2010, none of the qualified disaster
recovery assistance distribution is
included in income. The excess
repayment of $15,000 ($45,000 $30,000) can be carried back to 2009 or
you can choose to carry it forward to
2011.
File Form 1040X, Amended U.S.
Individual Income Tax Return, to amend a
return you have already filed. Generally,
Form 1040X must be filed within 3 years
after the date the original return was filed,
or within 2 years after the date the tax
was paid, whichever is later.

Specific Instructions
Name and social security number
(SSN). If you file a joint return, enter only
the name and SSN of the spouse whose
information is being reported on Form
8930. If both you and your spouse are
required to file Form 8930, file a separate
Form 8930 for each of you. If you and
your spouse are both filing Forms 8930,
the $100,000 limit on qualified disaster
recovery assistance distributions and the
election to include all qualified disaster
recovery assistance distributions in
income are determined separately for
each spouse.

Exceptions. You cannot repay the
following types of distributions.
1. Qualified disaster recovery
assistance distributions received as a
beneficiary (other than a surviving
spouse).
2. Required minimum distributions.
3. Periodic payments (other than from
an IRA) that are for:
a. A period of 10 years or more,
b. Your life or life expectancy, or
c. The joint lives or life expectancies
of you and your beneficiary.

Part I—Total Distributions
From All Retirement Plans
(Including IRAs)

Note. If you included repayments on
your 2008 Form 8930, do not include
those repayments on your 2009 Form
8930.

Complete Part I only if you have
qualified disaster recovery
CAUTION assistance distributions for 2009
and the total of your qualified disaster

!

-2-

recovery assistance distributions for
2008, if any, was less than $100,000.

Column (a)
If you received a distribution from a
retirement plan (including an IRA), you
should receive a Form 1099-R. The
amount of the distribution should be
shown in Form 1099-R, box 1. Enter the
amounts from all your Forms 1099-R, box
1, on the appropriate lines in column (a).

Column (b)
Enter on the appropriate lines in column
(b) any qualified disaster recovery
assistance distributions (including
periodic payments and required minimum
distributions) you received in 2009.
Include only those distributions you
wish to designate as qualified disaster
recovery assistance distributions. See
Qualified Disaster Recovery Assistance
Distribution on page 1.

Column (c)
Complete column (c) only if the total on
line 5, column (b), is more than $100,000.
If the amount on line 5, column (b), is
more than $100,000, you will need to
make an allocation in column (c) of the
distribution(s) included in column (b). This
is because the total of your qualified
disaster recovery assistance distributions
cannot exceed the $100,000 limit. If you
have distributions from more than one
type of retirement plan, such as an IRA
and a pension plan, you can allocate the
$100,000 limit among the plans any way
you choose.
Example 1. You received a
distribution from your Roth IRA in the
amount of $130,000 on September 1,
2009, because of the severe storms in the
Midwestern disaster areas. You would
enter $130,000 on line 4, columns (a) and
(b). You would then enter $100,000 on
line 4, column (c), since the distribution is
in excess of the $100,000 limit.
Example 2. Assume the same facts
as in Example 1, except on October 14,
2009, you also received a distribution
from your 401(k) plan in the amount of
$20,000 because of the severe storms in
the Midwestern disaster areas. You would
enter $20,000 on line 2, columns (a) and
(b). You will now need to make an
allocation in column (c) between the two
distributions, since the total on line 5,
column (b), is $150,000. You can choose
to make the allocation in any way, as long
as the total in column (c) does not exceed
$100,000. You choose to allocate
$80,000 to your Roth IRA distribution on
line 4, column (c), and the entire $20,000
to your 401(k) plan distribution on line 2,
column (c).

Part II—Qualified Disaster
Recovery Assistance
Distributions From
Retirement Plans (other
than IRAs)
Complete Part II if any of the following
apply.
• You entered an amount on line 2,
column (b).
• You had an amount on your 2008 Form
8930, line 9, and you did not check the
box on that line.
Instructions for Form 8930 (2009)

Page 3 of 4

Instructions for Form 8930 (2009)

9:36 - 7-DEC-2009

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

• You made a repayment of a qualified

disaster recovery assistance distribution.

Line 9
Enter on line 9 your cost, if any. Your cost
is generally your net investment in the
plan. It does not include pre-tax
contributions. If there is an amount in
Form 1099-R, box 2a (taxable amount),
the difference between Form 1099-R, box
1, and box 2a, is usually your cost. Enter
the difference on line 9.
If there is no amount in Form 1099-R,
box 2a, and the first box in box 2b is
checked, the issuer of Form 1099-R may
not have had all the facts needed to figure
the taxable amount. You may want to get
Pub. 575, Pension and Annuity Income,
to help figure your taxable amount.
Also, see Pub. 575 if you use the
Simplified Method Worksheet to figure the
taxable amount of your periodic payments
and you designated some of these
payments as qualified disaster recovery
assistance distributions.
If you have a Form 1099-R with
both qualified disaster recovery
CAUTION assistance distributions and
non-qualified distributions, you must
separately calculate the cost attributable
to each distribution.

!

Line 11
If you do not check the box on line 11,
you must spread the amount on line 10
over 3 years. If you use this method to
figure the taxable amount of your
distributions, you cannot change it after
the due date (including extensions) for
your tax return.
If the taxpayer died during 2009 after
receiving a qualified disaster recovery
assistance distribution, the distribution
cannot be spread over 3 years. The entire
distribution (including any remaining
amounts from 2008) must be reported on
the tax return of the deceased taxpayer.

Line 17
At any time during the 3-year period after
the date you received a qualified disaster
recovery assistance distribution, you can
repay any portion of the distribution to an
eligible retirement plan that is permitted to
accept rollover contributions. You cannot,
however, repay more than the amount of
the original distribution. See Repayment
of a Qualified Disaster Recovery
Assistance Distribution on page 2 for
details.
Enter on line 17 the amount of any
repayments you made before filing your
2009 return. Do not include any
repayments made later than the due date
(including extensions) for that return. If
you repaid more than the amount on line
13 (including any excess repayments
from 2008 on line 16), the excess will be
carried forward to your 2010 tax return.
Repayments made after the due date of
your 2009 return (including extensions)
generally will be reported on your 2010
tax return. However, you may have to file
an amended return in certain situations.
See Amending Form 8930 on page 2.
Do not include on line 17
repayments of qualified disaster
CAUTION recovery assistance distributions
made after 2008 that were included on
your 2008 Form 8930.

!

Instructions for Form 8930 (2009)

Example. You received a $90,000
qualified disaster recovery assistance
distribution on June 9, 2009, from your
401(k) plan because of the severe storms
in the Midwestern disaster areas. On April
1, 2010, you repay $30,000 to an IRA.
You file your return on April 10, 2010.
Since the repayment was made before
you filed your return, and not later than
the due date (including extensions), you
would enter the $30,000 repayment on
line 17.

Part III—Qualified Disaster
Recovery Assistance
Distributions From
Traditional, SEP, SIMPLE,
and Roth IRAs
Complete Part III if any of the following
apply.
• You entered an amount on line 3,
column (b).
• You entered an amount on line 4,
column (b).
• You had an amount on your 2008 Form
8930, line 17, and you did not check the
box on that line.
• You made a repayment of a qualified
disaster recovery assistance distribution.
Before completing this section,
complete Form 8606 if either of the
following applies.
• You received a qualified disaster
recovery assistance distribution from a
traditional, SEP, or SIMPLE IRA, and you
have a basis in the IRA.
• You received a qualified disaster
recovery assistance distribution from a
Roth IRA.
For more information, see Form 8606
and its instructions.

Line 26
If you do not check the box on line 26,
you must spread the amount on line 25
over 3 years. If you use this method to
figure the taxable amount of your
distributions, you cannot change it after
the due date (including extensions) for
your tax return.
If the taxpayer died during 2009 after
receiving a qualified disaster recovery
assistance distribution, the distribution
cannot be spread over 3 years. The entire
distribution (including any remaining
amounts from 2008) must be reported on
the tax return of the deceased taxpayer.

Line 32
At any time during the 3-year period after
the date you received a qualified disaster
recovery assistance distribution, you can
repay any portion of the distribution to an
eligible retirement plan that is permitted to
accept rollover contributions. You cannot,
however, repay more than the amount of
the original distribution. See Repayment
of a Qualified Disaster Recovery
Assistance Distribution on page 2 for
details.
Enter on line 32 the amount of any
repayments you made before filing your
2009 return. Do not include any
repayments made later than the due date
(including extensions) for that return. If
you repaid more than the amount on line
28 (including any excess repayments

-3-

from 2008 on line 31), the excess will be
carried forward to your 2010 tax return.
Repayments made after the due date of
your 2009 return (including extensions)
generally will be reported on your 2010
tax return. However, you may have to file
an amended return in certain situations.
See Amending Form 8930 on page 2.
Do not include on line 32
repayments of qualified disaster
CAUTION recovery assistance distributions
made after 2008 that were included on
your 2008 Form 8930.
Example. You received a $90,000
qualified disaster recovery assistance
distribution on October 1, 2009, from your
Roth IRA because of the severe storms in
the Midwestern disaster areas. On April 1,
2010, you repay $30,000 to your Roth
IRA. You file your return on April 10,
2010. Since the repayment was made
before you filed your return, and not later
than the due date (including extensions),
you would enter the $30,000 repayment
on line 32.

!

Privacy Act and Paperwork Reduction
Act Notice. We ask for the information
on this form to carry out the Internal
Revenue laws of the United States. We
need this information to ensure that you
are complying with these laws and to
allow us to figure and collect the right
amount of tax. You are required to give us
this information if you made certain
contributions or received certain
distributions from qualified plans,
including IRAs, and other tax-favored
accounts. Our legal right to ask for the
information requested on this form is
sections 6001, 6011, 6012(a), and 6109
and their regulations. If you do not
provide this information, or you provide
incomplete or false information, you may
be subject to penalties.
You are not required to provide the
information requested on a form that is
subject to the Paperwork Reduction Act
unless the form displays a valid OMB
control number. Books or records relating
to a form or its instructions must be
retained as long as their contents may
become material in the administration of
any Internal Revenue law. Generally, tax
returns and return information are
confidential, as required by section 6103.
However, we may give this information to
the Department of Justice for civil and
criminal litigation, and to cities, states, the
District of Columbia, and U.S.
commonwealths and possessions to carry
out their tax laws. We may also disclose
this information to other countries under a
tax treaty, to federal and state agencies to
enforce federal nontax criminal laws, or to
federal law enforcement and intelligence
agencies to combat terrorism.
The average time and expenses
required to complete and file this form will
vary depending on individual
circumstances. For the estimated
averages, see the instructions for your
income tax return.
If you have suggestions for making this
form simpler, we would be happy to hear
from you. See the instructions for your
income tax return.

Page 4 of 4

Instructions for Form 8930 (2009)

9:36 - 7-DEC-2009

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Table 1. Midwestern Disaster Areas
The counties listed below are in the Midwestern disaster areas and are eligible for the special tax relief discussed in these instructions.
Applicable
Disaster Dates*

State

Affected Counties — Midwestern Disaster Areas

05/02/2008
through
05/12/2008

Arkansas

Arkansas, Benton, Cleburne, Conway, Crittenden, Grant, Lonoke, Mississippi, Phillips, Pulaski, Saline,
and Van Buren.

06/01/2008
through
07/22/2008

Illinois

Adams, Calhoun, Clark, Coles, Crawford, Cumberland, Douglas, Edgar, Greene, Hancock,
Henderson, Jasper, Jersey, Lake, Lawrence, Madison, Mercer, Monroe, Pike, Randolph, Rock Island,
St. Clair, Scott, Whiteside, and Winnebago.

05/30/2008
through
06/27/2008

Indiana

Adams, Bartholomew, Benton, Boone, Brown, Clay, Daviess, Dearborn, Decatur, Fountain, Franklin,
Gibson, Grant, Greene, Hamilton, Hancock, Hendricks, Henry, Huntington, Jackson, Jay, Jefferson,
Jennings, Johnson, Knox, Lawrence, Madison, Marion, Montgomery, Monroe, Morgan, Ohio, Owen,
Parke, Pike, Posey, Putnam, Randolph, Ripley, Rush, Shelby, Sullivan, Switzerland, Tippecanoe,
Union, Vermillion, Vigo, Wabash, Washington, and Wayne.

05/25/2008
through
08/13/2008

Iowa

Adair, Adams, Allamakee, Appanoose, Audubon, Benton, Black Hawk, Boone, Bremer, Buchanan,
Butler, Carroll, Cass, Cedar, Cerro Gordo, Cherokee, Chickasaw, Clarke, Clayton, Clinton, Crawford,
Dallas, Davis, Decatur, Delaware, Des Moines, Dubuque, Fayette, Floyd, Franklin, Fremont, Greene,
Grundy, Guthrie, Hamilton, Hancock, Hardin, Harrison, Henry, Howard, Humboldt, Iowa, Jackson,
Jasper, Johnson, Jones, Keokuk, Kossuth, Lee, Linn, Louisa, Lucas, Lyon, Madison, Mahaska,
Marion, Marshall, Mills, Mitchell, Monona, Monroe, Montgomery, Muscatine, Page, Palo Alto,
Pocahontas, Polk, Pottawattamie, Poweshiek, Ringgold, Scott, Story, Tama, Taylor, Union, Van
Buren, Wapello, Warren, Washington, Wayne, Webster, Winnebago, Winneshiek, Worth, and Wright.

05/22/2008
through
06/16/2008

Kansas

Barber, Barton, Bourbon, Brown, Butler, Chautauqua, Cherokee, Clark, Clay, Comanche, Cowley,
Crawford, Decatur, Dickinson, Edwards, Elk, Ellis, Ellsworth, Franklin, Gove, Graham, Harper, Haskell,
Hodgeman, Jackson, Jewell, Kingman, Kiowa, Lane, Linn, Logan, Mitchell, Montgomery, Ness,
Norton, Osborne, Pawnee, Phillips, Pratt, Reno, Republic, Riley, Rooks, Rush, Saline, Seward,
Sheridan, Smith, Stafford, Sumner, Thomas, Trego, Wallace, and Wilson.

06/06/2008
through
06/13/2008

Michigan

Allegan, Barry, Eaton, Ingham, Lake, Manistee, Mason, Missaukee, Osceola, Ottawa, Saginaw, and
Wexford.

06/06/2008
through
06/12/2008

Minnesota Cook, Fillmore, Freeborn, Houston, Mower, and Nobles.

05/10/2008
through
05/11/2008

Missouri

Barry, Jasper, and Newton.

06/01/2008
through
08/13/2008

Missouri

Adair, Andrew, Atchison, Audrain, Bates, Buchanan, Callaway, Cape Girardeau, Carroll, Cass,
Chariton, Christian, Clark, Daviess, Gentry, Greene, Grundy, Harrison, Holt, Howard, Jefferson,
Johnson, Knox, Lewis, Lincoln, Linn, Livingston, Macon, Marion, Mercer, Miller, Mississippi, Monroe,
Morgan, New Madrid, Nodaway, Pemiscot, Perry, Pettis, Pike, Platte, Polk, Putnam, Ralls, Randolph,
Ray, Saline, Schuyler, Scotland, Shelby, St. Charles, St. Genevieve, St. Louis, the Independent City of
St. Louis, Scott, Stone, Sullivan, Taney, Vernon, Webster, and Worth.

04/23/2008
through
04/26/2008

Nebraska Gage, Johnson, Morrill, Nemaha, and Pawnee.

05/22/2008
through
06/24/2008

Nebraska Adams, Blaine, Boone, Boyd, Brown, Buffalo, Burt, Butler, Cass, Chase, Cherry, Colfax, Cuming,
Custer, Dawson, Douglas, Dundy, Fillmore, Frontier, Furnas, Gage, Garfield, Gosper, Greeley, Hall,
Hamilton, Hayes, Holt, Howard, Jefferson, Johnson, Kearney, Keya Paha, Lancaster, Lincoln, Logan,
Loup, Merrick, McPherson, Morrill, Nance, Nemaha, Otoe, Phelps, Platte, Polk, Red Willow,
Richardson, Rock, Saline, Sarpy, Saunders, Seward, Sherman, Stanton, Thayer, Thomas, Thurston,
Valley, Webster, Wheeler, and York.

06/27/2008

Nebraska Dodge, Douglas, Sarpy, and Saunders.

06/05/2008
through
07/25/2008

Wisconsin Adams, Calumet, Crawford, Columbia, Dane, Dodge, Fond du Lac, Grant, Green, Green Lake, Iowa,
Jefferson, Juneau, Kenosha, La Crosse, Lafayette, Manitowoc, Marquette, Milwaukee, Monroe,
Ozaukee, Racine, Richland, Rock, Sauk, Sheboygan, Vernon, Walworth, Washington, Waukesha, and
Winnebago.

*For more details, go to www.fema.gov.

-4-

Instructions for Form 8930 (2009)