8915-B Qualified 2017 Disaster Retirement Plan Distributions an

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Form

Qualified 2017 Disaster Retirement
Plan Distributions and Repayments

8915-B
▶

Department of the Treasury
Internal Revenue Service

OMB No. 1545-0074

2021

Go to www.irs.gov/Form8915B for instructions and the latest information.
▶ For coronavirus-related distributions, see Form 8915-F.
▶ Attach to 2021 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 2021 Form 8915-B. See instructions.

DRAFT AS OF
September 13, 2021
DO NOT FILE
Home address (number and street, or P.O. box if mail is not delivered to your home)

▲

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

Part I

1a
1b
2a
2b
3
4

5

7b
8
9

10

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

1a
1b
2a

2b
Subtract line 2b from line 2a. If zero, enter -0- . . . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made in 2021 that were not included on your 2020
Form 8915-B. But don’t include repayments made after the 3-year cutoff date. Don’t use this form to
report repayments of qualified 2018, 2019, or 2020 disaster distributions. 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 . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

4
5

Qualified 2017 Disaster Distributions From Traditional, SEP, SIMPLE, and Roth IRAs

Enter the amount, if any, from your 2020 Form 8915-B, line 13 . . . .
Enter the amount, if any, from your 2020 Form 8915-B, line 8 . . . . .
Subtract line 6b from line 6a. If zero or less, enter -0-. This is your excess
repayment from 2020 . . . . . . . . . . . . . . . . . .
Enter the amount from line 7a that you have already carried back to a prior
year . . . . . . . . . . . . . . . . . . . . . . . .

.
.

6a
6b

.

7a

.

7b
Subtract line 7b from line 7a. If zero, enter -0- . . . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made in 2021 that were not included on your 2020
Form 8915-B. But don’t include repayments made after the 3-year cutoff date. Don’t use this form to
report repayments of qualified 2018, 2019, or 2020 disaster distributions. 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 . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

If this is an
amended return,
check here ▶

Qualified 2017 Disaster Distributions From Retirement Plans (Other Than IRAs)

Enter the amount, if any, from your 2020 Form 8915-B, line 6 . . . . . .
Enter the amount, if any, from your 2020 Form 8915-B, line 1 . . . . . .
Subtract line 1b from line 1a. If zero or less, enter -0-. This is your excess
repayment from 2020 . . . . . . . . . . . . . . . . . . .
Enter the amount from line 2a that you have already carried back to a prior
year. . . . . . . . . . . . . . . . . . . . . . . . .

Part II
6a
6b
7a

Apt. no.

Your signature

Print/Type preparer’s name
Firm’s name

▶

Firm’s address

▶

Preparer’s signature

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

Date

Date
Check
if
self-employed
Firm’s EIN

PTIN

▶

Phone no.
Cat. No. 71180D

Form 8915-B (2021)