Form 8930 Qualified Disaster Recovery Assistance Retirement Plan D

Form

8930

Department of the Treasury
Internal Revenue Service

©

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

1
2
3
4
5
6
7

8
9

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

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

Qualified Disaster Recovery Assistance Distributions From Retirement Plans (Other Than IRAs)
1
2
3

6

7
8
9

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

12

Enter the amount, if any, from your 2008 Form 8930, line 17, only if you did not check the box
on that line
Enter the amount, if any, from your 2009 Form 8930, line 26, only if you did not check the box
on that line
Add lines 10 and 11

13

Enter the amount, if any, from your 2009 Form 8930, line 33

13

14

Enter the amount, if any, from your 2009 Form 8930, line 28

14

15

Subtract line 14 from line 13. If zero or less, enter -0-

15

16

Enter the total amount of any repayments you made before filing your 2010 tax return. But do
not include repayments made later than the due date (including extensions) for that return.
See instructions

16

17

Add lines 15 and 16

17

18

Amount subject to tax in 2010. Subtract line 17 from line 12. 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

11

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

Firm’s name

©

11
12

18

©

Your signature
Preparer’s signature

©

Firm’s address

10

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.

Print/Type preparer’s name

Paid
Preparer
Use Only

164

Your social security number

Enter the amount, if any, from your 2008 Form 8930, line 9, only if you did not check the box on
that line
Enter the amount, if any, from your 2009 Form 8930, line 11, only if you did not check the box
on that line
Add lines 1 and 2
4
Enter the amount, if any, from your 2009 Form 8930, line 18
5
Enter the amount, if any, from your 2009 Form 8930, line 13
Subtract line 5 from line 4. If zero or less, enter -0Enter the total amount of any repayments you made before filing your 2010 tax return. But do
not include repayments made later than the due date (including extensions) for that return. See
instructions
Add lines 6 and 7
Amount subject to tax in 2010. Subtract line 8 from line 3. 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

Part II
10

©

2010

Attachment
Sequence No.

Name. If married, file a separate form for each spouse required to file Form 8930. See instructions.

Part I

OMB No. 1545-0074

Qualified Disaster Recovery Assistance
Retirement Plan Distributions and Repayments

Date

Check
if
self-employed
Firm’s EIN

©

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

Date
PTIN

©

Phone no.
Cat. No. 37744P

Form

8930

(2010)