8915-A (2020 Draft)

Note: The draft you are looking for begins on the next page.

Caution: DRAFT—NOT FOR FILING
This is an early release draft of an IRS tax form, instructions, or publication,
which the IRS is providing for your information. Do not file draft forms and do
not rely on draft forms, instructions, and publications for filing. We do not
release draft forms until we believe we have incorporated all changes (except
when explicitly stated on this coversheet). However, unexpected issues
occasionally arise, or legislation is passed—in this case, we will post a new draft
of the form to alert users that changes were made to the previously posted draft.
Thus, there are never any changes to the last posted draft of a form and the final
revision of the form. Forms and instructions generally are subject to OMB
approval before they can be officially released, so we post only drafts of them
until they are approved. Drafts of instructions and publications usually have some
changes before their final release.
Early release drafts are at IRS.gov/DraftForms and remain there after the final
release is posted at IRS.gov/LatestForms. All information about all forms,
instructions, and pubs is at IRS.gov/Forms.
Almost every form and publication has a page on IRS.gov with a friendly
shortcut. For example, the Form 1040 page is at IRS.gov/Form1040; the Pub. 501
page is at IRS.gov/Pub501; the Form W-4 page is at IRS.gov/W4; and the
Schedule A (Form 1040/SR) page is at IRS.gov/ScheduleA. If typing in a link
above instead of clicking on it, be sure to type the link into the address bar of your
browser, not a Search box.
If you wish, you can submit comments to the IRS about draft or final forms,
instructions, or publications at IRS.gov/FormsComments. We cannot respond to
all comments due to the high volume we receive and may not be able to consider
many suggestions until the subsequent revision of the product.
If you have comments on reducing paperwork and respondent (filer) burden,
with respect to draft or final forms, please respond to the relevant information
collection through the Federal Register process; for more info, click here.

Form

8915-A

Qualified 2016 Disaster Retirement
Plan Distributions and Repayments
▶

Department of the Treasury
Internal Revenue Service

OMB No. 1545-0074

2020

Go to www.irs.gov/Form8915A for instructions and the latest information.
▶ For coronavirus-related distributions, see Form 8915-E.
▶ Attach to 2020 Form 1040, 1040-SR, or 1040-NR.

Attachment
Sequence No. 915
Your social security number

Name. If married, file a separate form for each spouse required to file 2020 Form 8915-A. See instructions.

DRAFT AS OF
November 6, 2020
DO NOT FILE
Home address (number and street, or P.O. box if mail is not delivered to your home)

Part I

▲

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

Apt. no.

City, town or post office, state, and ZIP code. If you have a foreign address, also complete the spaces below (see instructions).
Foreign country name

Foreign province/state/county

Foreign postal code

Qualified 2016 Disaster Distributions From Retirement Plans (Other Than IRAs)

1
2
3
4

Enter the amount, if any, from your 2019 Form 8915-A, line 6 . . . . . .
1
Enter the amount, if any, from your 2019 Form 8915-A, line 1 . . . . . .
2
Subtract line 2 from line 1. If zero or less, enter -0- . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made before filing your 2020 tax return. But do not
include repayments made later than the due date (including extensions) for that return or after the
3-year cutoff date. Do not use this form to report repayments of qualified 2017, 2018, 2019, or 2020
disaster distributions from retirement plans (other than IRAs). See instructions . . . . . . . .

5

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

4
5

Qualified 2016 Disaster Distributions From Traditional, SEP, SIMPLE, and Roth IRAs

6
7
8
9

Enter the amount, if any, from your 2019 Form 8915-A, line 13 . . . . .
6
Enter the amount, if any, from your 2019 Form 8915-A, line 8 . . . . . .
7
Subtract line 7 from line 6. If zero or less, enter -0- . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made before filing your 2020 tax return. But do not
include repayments made later than the due date (including extensions) for that return or after the
3-year cutoff date. See instructions. Do not use this form to report repayments of qualified 2017,
2018, 2019, or 2020 disaster distributions from IRAs, but see the Caution in Line 9 in the instructions

10

Add lines 8 and 9. This amount can be carried back to reduce the amount subject to tax in a prior
year. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

9
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.

▲

▲

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

Paid
Preparer
Use Only

3

Your signature

Print/Type preparer’s name

Preparer’s signature

Date

Date
Check
if
self-employed

▶

Firm’s EIN

Firm’s address ▶

Phone no.

Firm’s name

For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions.

Cat. No. 71167K

PTIN

▶

Form 8915-A (2020)