U.S. Individual Income Tax Return Forms

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Form

8915-D

Qualified 2019 Disaster Retirement
Plan Distributions and Repayments

▶

Department of the Treasury
Internal Revenue Service

OMB No. 1545-0074

Go to www.irs.gov/Form8915D for instructions and the latest information.
▶ For coronavirus-related distributions, see Form 8915-E.
▶ Attach to 2020 Form 1040, 1040-SR, or 1040-NR.

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

2020
Attachment
Sequence No. 915
Your social security number

DRAFT AS OF
November 9, 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

If this is an amended
return, check here ▶

Foreign postal code

Total Distributions From All Retirement Plans (Including IRAs)

Before you begin:

• Complete this part only if you have qualified 2019 disaster distributions in 2020 and the total of your qualified 2019 disaster distributions in 2019, if
any, for each disaster reported in 2020 was less than $100,000. See instructions.
• Complete 2020 Form 8915-C, Qualified 2018 Disaster Retirement Plan Distributions and Repayments, if applicable.
• If you completed Part I of 2020 Form 8915-C, see the Caution in Column (a) in the instructions to figure the amounts for column (a).
• See Table 1 in the instructions for the list of qualified 2019 disasters.

• If you are reporting distributions in Part I for more than one 2019 disaster, see the instructions to determine whether you should use Worksheet 2 to
figure the amounts to enter in Part I, column (b), below. If you must use Worksheet 2, check this box ▶

Complete line 1 first. Then, complete lines 2 through 5 of one column before going to the next column.
Caution: A 2020 distribution can’t be a qualified 2019 disaster distribution unless it was made before
June 17, 2020.
Disaster name ▶
Date last distribution made ▶

1

(a)
Total
distributions
in 2020

(b)
(c)
Qualified 2019 Allocation of
disaster
column (b)
distributions (see instructions)
(see instructions)

If you are reporting only one disaster for 2020, enter in columns (b) and (c) the amount
described below for your situation. Otherwise, see Worksheet 2 in the instructions.
• If you did not file 2019 Form 8915-D, enter -0-.
• If you filed 2019 Form 8915-D, and the disaster for which you are reporting distributions on this form is
different from the disaster(s) for which you reported distributions on 2019 Form 8915-D, enter -0-.
• If you filed 2019 Form 8915-D, you reported distributions for only one disaster on that
form, and you are reporting distributions for that same disaster on this form, enter the
amount from your 2019 Form 8915-D, line 4, column (b).
• If you filed 2019 Form 8915-D on which you reported distributions for more than one disaster and one
of those disasters is the disaster for which you are reporting distributions on this form, enter the
amount for that disaster from line 4 of column (X) in Worksheet 2 in the 2019 Form 8915-D instructions.
• If your situation is not described above, see Worksheet 2 in the instructions.
If you are reporting only one disaster for 2020 and the amount you are entering in
column (b) is $100,000 or more, do not complete this part; you have no qualified 2019
disaster distributions in 2020 . . . . . . . . . . . . . . . . . .

2
3
4
5

Distributions from retirement plans (other than IRAs) made in 2020 . . . . . .
Distributions from traditional, SEP, and SIMPLE IRAs made in 2020 . . . . . .
Distributions from Roth IRAs made in 2020
. . . . . . . . . . . . .
Totals. Add lines 1 through 4 in columns (a) and (b). If line 5, column (b), is more than
$100,000 and you did not use Worksheet 2, you must complete column (c). Otherwise,
leave column (c) blank. See Column (c) in the instructions . . . . . . . . .

6

Subtract line 1 in column (c) from $100,000

7

If you completed column (c), enter the excess of the amount on line 5, column (a), over the amount on line 6,
column (c). Otherwise, enter the excess of the amount on line 5, column (a), over the sum of the amounts on
lines 2 through 4 in column (b). Report these distributions under the normal rules in accordance with the
instructions for your tax return
. . . . . . . . . . . . . . . . . . . . . . . . .

Part II
8

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11

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100,000

.

Qualified 2019 Disaster Distributions From Retirement Plans (Other Than IRAs)

Did you enter an amount on line 2, column (b)?
No. Skip lines 8 through 11, and go to line 12.
Yes. If you completed line 2, column (c), enter that amount. Otherwise, enter the amount from line 2, column (b)
Enter the applicable cost of distributions, if any. See instructions . . . . . . . . . . . . . . .
Subtract line 9 from line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . .
If you elect not to spread the taxable amount over 3 years, check this box ▶
and enter the amount from line
10 (see instructions). You must check this box if you check the box on line 26. Otherwise, divide line 10 by 3.0

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

Cat. No. 73793G

7

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10
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Form 8915-D (2020)

Page 2

Form 8915-D (2020)

Part II
12
13
14
15
16
17

Qualified 2019 Disaster Distributions From Retirement Plans (Other Than IRAs) (continued)
12
13
14

Enter the amount, if any, from your 2019 Form 8915-D, line 9. If you checked the box on that line, enter -0- .
Add lines 11 and 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the amount, if any, from your 2019 Form 8915-D, line 10 . . . . . . . . . . . . . . .
Enter the amount, if any, from your 2019 Form 8915-D, line 9 . . . . . . . . . .
15
Subtract line 15 from line 14. 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. Do not use this form to report
repayments of qualified 2016, 2017, 2018, or 2020 disaster distributions. See instructions . . . . . . .

16

DRAFT AS OF
November 9, 2020
DO NOT FILE
17
18

18
19

Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2020. Subtract line 18 from line 13. If zero or less, enter -0-. Include this amount in
the total on 2020 Form 1040, 1040-SR, or 1040-NR, line 5b . . . . . . . . . . . . . . . .
Before you begin: Complete 2020 Form 8606, Nondeductible IRAs, if required.

Part III

19

Qualified 2019 Disaster Distributions From Traditional, SEP, SIMPLE, and Roth IRAs

20

Did you enter an amount on line 3, column (b), or line 4, column (b)?
Yes. Go to line 21.
No. Skip lines 21 through 26, and go to line 27.

21

Did you receive a qualified 2019 disaster distribution from a traditional, SEP, SIMPLE, or Roth IRA that is required
to be reported on 2020 Form 8606?
Yes. Go to line 22.
No. Skip lines 22 and 23, and go to line 24.
Enter the amount, if any, from 2020 Form 8606, line 15b. But if you are entering amounts here and on 2020
Form 8915-C, line 23, or Form 8915-E, line 13, only enter on line 22 the amount on Form 8606, line 15b,
attributable to Form 8915-D distributions. See the instructions for Form 8606, line 15b . . . . . . . .

22

23

Enter the amount, if any, from 2020 Form 8606, line 25b. But if you are entering amounts here and on 2020
Form 8915-C, line 24, or Form 8915-E, line 14, only enter on line 23 the amount on Form 8606, line 25b,
attributable to Form 8915-D distributions. See the instructions for Form 8606, line 25b . . . . . . . .

23

24

If you completed line 3, column (c), enter that amount. Otherwise, enter the amount from line 3, column (b), if
any. Don’t include on line 24 any amounts reported on 2020 Form 8606 . . . . . . . . . . . .

24

25
26

Add lines 22, 23, and 24 . . . . . . . . . . . . . . . . . . . . . . . . . . .
If you elect not to spread the taxable amount over 3 years, check this box ▶
and enter the amount from line
25 (see instructions). You must check this box if you check the box on line 11. Otherwise, divide line 25 by 3.0

27
28
29
30
31
32

Enter the amount, if any, from your 2019 Form 8915-D, line 17. If you checked the box on that line, enter -0- .
Add lines 26 and 27 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the amount, if any, from your 2019 Form 8915-D, line 18 . . . . . . . . .
29
Enter the amount, if any, from your 2019 Form 8915-D, line 17 . . . . . . . . .
30
Subtract line 30 from line 29. 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. Do not use this form to report
repayments of qualified 2016, 2017, 2018, or 2020 disaster distributions. See instructions . . . . . . .

33
34

Add lines 31 and 32 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2020. Subtract line 33 from line 28. If zero or less, enter -0-. Include this amount in
the total on 2020 Form 1040, 1040-SR, or 1040-NR, line 4b . . . . . . . . . . . . . . . .

22

Part IV

25
26
27
28

31

32
33
34

Qualified Distributions for the Purchase or Construction of a Main Home in Qualified 2019 Disaster Areas
Reserved for future use. Leave Part IV blank. See instructions.

Caution: If you are repaying, before June 18, 2020, a qualified distribution received in 2019 for the purchase or construction of a main home in a 2019 disaster
area, report the repayment on an amended 2019 Form 8915-D, Part IV, or an amended tax return, as applicable. See Part IV under Specific Instructions in the
instructions. If the qualified distribution was received in 2018, see 2018 qualified distributions under Amending Form 8915-D in the instructions.

35

This line is reserved for future use. If needed in the future, this line would be used for the Taxable amount and
will provide the Form 1040, 1040-SR, or 1040-NR line on which that amount should be placed.

▲

Paid
Preparer
Use Only

Your signature

Print/Type preparer’s name

Preparer’s signature

Date

Date
Check
if PTIN
self-employed

▶

Firm’s EIN

Firm’s address ▶

Phone no.

Firm’s name

35

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

▶

Form 8915-D (2020)