8915-C Qualified 2018 Disaster RetirementPlan Distributions and

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Form

8915-C

Qualified 2018 Disaster Retirement
Plan Distributions and Repayments
▶

Department of the Treasury
Internal Revenue Service

OMB No. 1545-0074

2021

Go to www.irs.gov/Form8915C 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-C. 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)

Part I
1
2
3
4a
b
5a

b
6
7

8
9

b
15
16

17
18

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

Qualified 2018 Disaster Distributions From Retirement Plans (Other Than IRAs)

1
2
3

Enter the amount, if any, from your 2019 Form 8915-C, line 11. If you checked the box on that line, enter -0Enter the amount, if any, from your 2020 Form 8915-C, line 11. If you checked the box on that line, enter -0Add lines 1 and 2
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the amount, if any, from your 2020 Form 8915-C, line 19 . . . . . .
4a
Enter the amount, if any, from your 2020 Form 8915-C, line 14 . . . . . .
4b
Subtract line 4b from line 4a. If zero or less, enter -0-. This is your excess repayment
from 2020 . . . . . . . . . . . . . . . . . . . . . . .
5a
Enter the amount from line 5a that you have already carried back to a prior year .
5b
Subtract line 5b from line 5a. If zero, enter -0. . . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made before filing your 2021 tax return. But don’t include
repayments made later than the due date (including extensions) for that return or after the 3-year cutoff
date. Don’t use this form to report repayments of qualified 2017, 2019, or 2020 disaster distributions. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Add lines 6 and 7
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2021. Subtract line 8 from line 3. If zero or less, enter -0-. Include this amount in
the total on 2021 Form 1040, 1040-SR, or 1040-NR, line 5b . . . . . . . . . . . . . . .

Part II
10
11
12
13a
b
14a

▲

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

Apt. no.

6

7
8
9

Qualified 2018 Disaster Distributions From Traditional, SEP, SIMPLE, and Roth IRAs

Enter the amount, if any, from your 2019 Form 8915-C, line 26. If you checked the box on that line, enter -0Enter the amount, if any, from your 2020 Form 8915-C, line 27. If you checked the box on that line, enter -0Add lines 10 and 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the amount, if any, from your 2020 Form 8915-C, line 35 . . . . . .
13a
Enter the amount, if any, from your 2020 Form 8915-C, line 30 . . . . . .
13b
Subtract line 13b from line 13a. If zero or less, enter -0-. This is your excess
repayment from 2020 . . . . . . . . . . . . . . . . . . .
14a
Enter the amount from line 14a that you have already carried back to a prior year .
14b
Subtract line 14b from line 14a. If zero, enter -0- . . . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made before filing your 2021 tax return. But don’t include any
repayments made later than the due date (including extensions) for that return or after the 3-year cutoff
date. Don’t use this form to report repayments of qualified 2017, 2019, or 2020 disaster distributions. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Add lines 15 and 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2021. Subtract line 17 from line 12. If zero or less, enter -0-. Include this amount
in the total on 2021 Form 1040, 1040-SR, or 1040-NR, line 4b
. . . . . . . . . . . . . .

10
11
12

15

16
17
18

Part III Qualified Distributions for the Purchase or Construction of a Main Home in Qualified 2018 Disaster Areas
Caution: If you repaid, before June 18, 2020, a qualified distribution received in 2018 or 2019 for the purchase or construction of a main
home in a qualified 2018 disaster area, report the repayment on an amended 2018 or 2019 Form 8915-C, Part IV, or an amended tax
return, as applicable. See Part III under Specific Instructions in the instructions. If the qualified distribution was received in 2017, see 2017
qualified distributions under Amending Form 8915-C in the instructions.

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Cat. No. 72465B

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Form 8915-C (2021)