8915-A Qualified 2016 Disaster Retirement Plan Distributions an

Form

8915-A

Qualified 2016 Disaster Retirement
Plan Distributions and Repayments

Department of the Treasury
Internal Revenue Service

▶

OMB No. 1545-0074

2019

Go to www.irs.gov/Form8915A for instructions and the latest information.
▶ Attach to 2019 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 2019 Form 8915-A. See instructions.
Home address (number and street, or P.O. box if mail is not delivered to your home)

Part I
1
2
3
4
5

6
7

9
10
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12

13
14

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)

Enter the amount, if any, from your 2017 Form 8915A, line 11. If you checked the box on that line,
enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the amount, if any, from your 2018 Form 8915A, line 8 . . . . . .
2
Enter the amount, if any, from your 2018 Form 8915A, 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 2019 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. If you are making repayments of amounts in 2017 or 2018 Form
8915B, Part II, file 2019 Form 8915-B to claim a repayment of those amounts . . . . . . . .

1

4

5
6

Add lines 4 and 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2019. Subtract line 6 from line 1. If zero or less, enter -0-. Include
this amount in the total on 2019 Form 1040 or 1040-SR, line 4d; or 2019 Form 1040-NR, line 17b . .

Part II
8

▲

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

Apt. no.

Enter the amount, if any, from your 2017 Form 8915A, line 26. If you checked the box on that line,
enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the amount, if any, from your 2018 Form 8915A, line 17
. . . . .
9
Enter the amount, if any, from your 2018 Form 8915A, line 12
. . . . .
10
Subtract line 10 from line 9. If zero or less, enter -0- . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made before filing your 2019 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. If you are making repayments of amounts in 2017 or 2018 Form
8915B, Part III, file 2019 Form 8915-B to claim a repayment of those amounts . . . . . . . .
Add lines 11 and 12 . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2019. Subtract line 13 from line 8. If zero or less, enter -0-. Include this
amount in the total on 2019 Form 1040 or 1040-SR, line 4b; or 2019 Form 1040-NR, line 16b . . .

8

11

12
13
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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.

Your signature

Print/Type preparer’s name

Firm’s name

▲

▲

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

Paid
Preparer
Use Only

7

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

Preparer’s signature

Date

Date
Check
if
self-employed

▶

Firm’s EIN

Firm’s address ▶

Phone no.

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

Cat. No. 71167K

PTIN

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Form 8915-A (2019)