8915-D Qualified 2019 Disaster Retirement Plan Distributions an

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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

2021

Go to www.irs.gov/Form8915D 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-D. 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

▲

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:

• Qualified 2019 disaster distributions can only be made in 2021 for the Puerto Rico Earthquakes disaster (DR-4473-PR). Those distributions must
have been made before June 25.
• Your qualified 2019 disaster distributions for the Puerto Rico Earthquakes disaster are limited to a total of $100,000. If your qualified 2019 disaster
distributions made in 2019 and 2020 for that disaster totaled $100,000, you do not have qualified 2019 disaster distributions available for that
disaster in 2021 and you should skip Part I. See instructions.
(a)
Total
distributions
in 2021

Complete line 1 first.
Date last distribution made ▶
1

(b)
Qualified 2019
disaster
distributions
(see instructions)

(c)
Allocation of
column (b)
(see instructions)

Enter in columns (b) and (c) the amount described below for your situation.
• If you didn’t file 2019 or 2020 Form 8915-D, enter -0-.
• If you filed 2019 or 2020 Form 8915-D, and the Puerto Rico Earthquakes
disaster was not a disaster for which you reported distributions on that prior
Form 8915-D, enter -0-.
• If you filed 2019 and 2020 Form 8915-D and you reported distributions for
only one disaster, the Puerto Rico Earthquakes disaster, on these forms,
enter the amount from your 2020 Form 8915-D, line 5, column (b).
• If you filed 2019 or 2020 Form 8915-D on which you reported distributions for
more than one disaster and one of those disasters is the Puerto Rico
Earthquakes disaster, enter the amount for the Puerto Rico Earthquakes
disaster from line 4 of column (X) in Worksheet 2 in the 2019 Form 8915-D
instructions or from line 5 of column (X) in Worksheet 2 in the 2020 Form
8915-D instructions, whichever is the latest one reporting that disaster.
If 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 2021

2
3
4

Distributions from retirement plans (other than IRAs) made in 2021 .
Distributions from traditional, SEP, and SIMPLE IRAs made in 2021 .
Distributions from Roth IRAs made in 2021
. . . . . . . .

5

Totals. Add lines 1 through 4 in columns (a) and (b). If line 5, column (b), is
more than $100,000, 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
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Part II
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100,000

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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)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9
10
11
12
13
14

7

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 27. Otherwise, divide line 10 by 3.0
Enter the amount, if any, from your 2019 Form 8915-D, line 9. If you checked the box on that line, enter -0Enter the amount, if any, from your 2020 Form 8915-D, line 11. If you checked the box on that line, enter -0Add lines 11, 12, and 13 . . . . . . . . . . . . . . . . . . . . . . . . . .

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 73793G

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Form 8915-D (2021)

Page 2

Form 8915-D (2021)

Part II

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

15a
b
16a

Enter the amount, if any, from your 2020 Form 8915-D, line 18 .
Enter the amount, if any, from your 2020 Form 8915-D, line 13 .
Subtract line 15b from line 15a. If zero or less, enter -0-. This
repayment from 2020 . . . . . . . . . . . . . .

b
17

Enter the amount from line 16a that you have already carried back to a prior year .
Subtract line 16b from line 16a. If zero, enter -0- . . . . . . . . . . .

18

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. Don’t use this form to report
repayments of qualified 2017, 2018, or 2020 disaster distributions. See instructions . . . . . . . .

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is
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your excess
. . . .

15a
15b
16a
16b
. . .

DRAFT AS OF
September 13, 2021
DO NOT FILE
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19
20

Add lines 17 and 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2021. Subtract line 19 from line 14. If zero or less, enter -0-. Include this amount
in the total on 2021 Form 1040, 1040-SR, or 1040-NR, line 5b
. . . . . . . . . . . . . .
Before you begin: Complete 2021 Form 8606, Nondeductible IRAs, if required.

Part III
21

22

17

18
19
20

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

Did you enter an amount on line 3, column (b), or line 4, column (b)?
Yes. Go to line 22.
No. Skip lines 22 through 27, and go to line 28.
Did you receive a qualified 2019 disaster distribution from a traditional, SEP, SIMPLE, or Roth IRA that is
required to be reported on 2021 Form 8606?
Yes. Go to line 23.
No. Skip lines 23 and 24, and go to line 25.

23

Enter the amount, if any, from 2021 Form 8606, line 15b. But if you are entering amounts here and on 2021
Form 8915-F, line 18, only enter on line 23 the amount on Form 8606, line 15b, attributable to Form 8915-D
distributions. See the instructions for Form 8606, line 15b . . . . . . . . . . . . . . . .

23

24

Enter the amount, if any, from 2021 Form 8606, line 25b. But if you are entering amounts here and on 2021
Form 8915-F, line 19, only enter on line 24 the amount on Form 8606, line 25b, attributable to Form 8915-D
distributions. See the instructions for Form 8606, line 25b . . . . . . . . . . . . . . . .

24

25

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 25 any amounts reported on 2021 Form 8606 . . . . . . . . . . .

26
27

Add lines 23, 24, and 25 . . . . . . . . . . . . . . . . . . . . . . . . . .
If you elect NOT to spread the taxable amount over 3 years, check this box ▶
and enter the amount from
line 26 (see instructions). You must check this box if you check the box on line 11. Otherwise, divide line 26 by 3.0
Enter the amount, if any, from your 2019 Form 8915-D, line 17. If you checked the box on that line, enter -0Enter the amount, if any, from your 2020 Form 8915-D, line 26. If you checked the box on that line, enter -0Add lines 27, 28, and 29 . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the amount, if any, from your 2020 Form 8915-D, line 33 . . . . . .
31a
Enter the amount, if any, from your 2020 Form 8915-D, line 28 . . . . . .
31b
Subtract line 31b from line 31a. If zero or less, enter -0-. This is your excess
repayment from 2020 . . . . . . . . . . . . . . . . . . .
32a
32b
Enter the amount from line 32a that you have already carried back to a prior year .
Subtract line 32b from line 32a. 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. Don’t use this form to report
repayments of qualified 2017, 2018, or 2020 disaster distributions. See instructions . . . . . . . .

28
29
30
31a
b
32a
b
33
34

35
36

Add lines 33 and 34 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2021. Subtract line 35 from line 30. If zero or less, enter -0-. Include this amount
in the total on 2021 Form 1040, 1040-SR, or 1040-NR, line 4b
. . . . . . . . . . . . . .

Part IV

25
26
27
28
29
30

33

34
35
36

Qualified Distributions for the Purchase or Construction of a Main Home in Qualified 2019 Disaster Areas

Caution: If you are repaying, before June 18, 2020 (before June 25, 2021, in the case of the Puerto Rico Earthquakes disaster), a qualified
distribution received in 2019 or 2020 for the purchase or construction of a main home in the qualified 2019 disaster area, report the repayment on an
amended 2019 or 2020 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.

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Form 8915-D (2021)