Form 8930 Qualified Disaster Recovery Assistance Retirement Plan D

Form

8930

Qualified Disaster Recovery Assistance
Retirement Plan Distributions and Repayments

Department of the Treasury
Internal Revenue Service

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OMB No. 1545-0074

2011

Attachment
Sequence No. 164

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

Your social security number

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

Part I

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

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

Enter the amount, if any, from your 2009 Form 8930, line 11, only if you did not check the box on
that line . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2
3
4
5

Enter the amount, if any, from your 2010 Form 8930, line 8 . . .
2
Enter the amount, if any, from your 2010 Form 8930, line 3 . . .
3
Subtract line 3 from line 2. If zero or less, enter -0- . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made before filing your 2011 tax return. But do
not include repayments made later than the due date (including extensions) for that return. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6
7

Add lines 4 and 5 . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2011. 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 .

Part II
8

1

4

5
6
7

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

Enter the amount, if any, from your 2009 Form 8930, line 26, only if you did not check the box on
that line . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

9

Enter the amount, if any, from your 2010 Form 8930, line 17 .

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9

10

Enter the amount, if any, from your 2010 Form 8930, line 12 .

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10

11

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

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12

Enter the total amount of any repayments you made before filing your 2011 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 2011. 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

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11

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14

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Your signature

Print/Type preparer’s name

Preparer’s signature

Date

Check
if
self-employed

Date
PTIN

Firm's EIN ▶

Firm's name ▶
Firm's address

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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.

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

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

Phone no.
Cat. No. 37744P

Form 8930 (2011)