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

2012

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
1
2
3
4

5

10

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)

Enter the amount, if any, from your 2011 Form 8930, line 6 . . .
1
Enter the amount, if any, from your 2011 Form 8930, line 1 . . .
2
Subtract line 2 from line 1. If zero or less, enter -0- . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made in 2012. But do not include repayments
made on or before the due date (including extensions) for filing your 2011 tax return. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Add lines 3 and 4. This amount can be carried back to reduce the amount subject to tax in a
prior year. See instructions . . . . . . . . . . . . . . . . . . . . . . .

Part II
6
7
8
9

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

3

4
5

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

Enter the amount, if any, from your 2011 Form 8930, line 13 . . .
6
Enter the amount, if any, from your 2011 Form 8930, line 8 . . .
7
Subtract line 7 from line 6. If zero or less, enter -0- . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made in 2012. But do not include repayments
made on or before the due date (including extensions) for filing your 2011 tax return. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Add lines 8 and 9. This amount can be carried back to reduce the amount subject to tax in a
prior year. See instructions . . . . . . . . . . . . . . . . . . . . . . .

10

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Your signature

Print/Type preparer’s name

Preparer’s signature

Firm's name ▶
Firm's address

9

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

8

Date

Check
if
self-employed

Date
PTIN

Firm's EIN ▶
▶

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

Phone no.
Cat. No. 37744P

Form 8930 (2012)