U.S. Individual Income Tax Return Forms

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Form

8915-F

(January 2022)

Qualified Disaster Retirement Plan
Distributions and Repayments
▶

Department of the Treasury
Internal Revenue Service

OMB No. 1545-0074

Complete items A and B below. Complete item C and check the box in item D for
the coronavirus, as applicable.
▶ Go to www.irs.gov/Form8915F for instructions and the latest information.
▶ Attach to 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 Form 8915-F. See instructions.

DRAFT AS OF
September 13, 2021
DO NOT FILE
Before you begin (see instructions for details):

• Form 8915-F replaces Form 8915-E for 2021 and later years. Form 8915-E was used for coronavirus-related and other 2020 disaster distributions.
• Form 8915-F is also used for 2021 and later disaster distributions. See the instructions for a list.
• See Table 1 in the instructions for the list of qualified disasters and their FEMA numbers for the year you check in item B next.
• “This year” (as used on this form) is the year of the form you check in item A next. For example, if you check 2021, “this year” is 2021.

A Tax year for which you are filing form (check only one box) ▶

2021

2022

2023

2024

Other

B Calendar year in which disaster occurred (check only one box) ▶

2020

2021

2022

2023

Other

C FEMA number for each of your disasters for the year checked in item B above. Use item D, not item C, for the coronavirus.
(1)

(2)

(3)

D If your disaster is the coronavirus, check this box ▶

(4)

(5)

(6)

Don’t list the coronavirus in item C.

Which lines on this form should I use? See CHARTS 1 and 2 below.

CHART 1: Use if you checked the box for coronavirus in item D above and you don’t have any disaster in item C.
No

▶ STOP! You can’t use Form 8915-F.
▶

Did you claim coronavirus-related distributions on 2020 Form 8915-E?

▶

▲

Start
here

Yes

▶

No
No

In item A above, did you check the box for tax year 2021 or 2022?

▶

In item A, did you check the box for
tax year 2023?

Yes

Yes

▶

▶
Yes

Did you check the box on line 9 or 17 on 2020 Form 8915-E?

▶

No

Are you repaying coronavirus-related
distributions?

No

Yes

▶

▶
Complete lines 12 through 15 and lines
23 through 26, as applicable.

Complete lines 14 and 25, as applicable.

CHART 2: Use if CHART 1 doesn’t apply to you. See the instructions for specific details.
Were qualified disaster distributions made to you
this year for a disaster listed in item C above?

No

▶

▶

Yes

No

▶

Complete Parts I, II, and III, and, if applicable, Part IV.

Yes

Did you claim qualified disaster distributions on a prior
year’s Form 8915-F (or on 2020 Form 8915-E if you checked
2020 in item B above) for disasters listed in item C?

No

Did you receive qualified distributions this year for the
purchase or construction of a main home in the area of a
disaster listed in item C?

Yes

Yes

No

Complete Part IV.

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

▶

Complete lines 14
and 25, as applicable.
Complete Part IV if
applicable.

No

▶

Complete lines 12 through
15 and lines 23 through 26,
as applicable. Complete
Part IV if applicable.

Yes

Are you repaying qualified
disaster distributions?

▶

▶

No

▶

▶

▶

▶

Is this the last year
for repayments?

Yes

▶

Did you check the box on line 11 or 22 on that prior year’s
Form 8915-F (or on line 9 or 17 of 2020 Form 8915-E if
you checked 2020 in item B) for disasters listed in item C?
No

Yes

Is the year in item A after the last year in which you can
make repayments? See instructions.

▶
Cat. No. 75585Y

STOP! You can’t use
Form 8915-F.

▶

▲

Start
here

Form 8915-F (1-2022)

Page 2

Form 8915-F (1-2022)

Part I

Total Distributions From All Retirement Plans (Including IRAs) (see instructions)
Provide the information requested below for the disasters in item C earlier for which you are reporting qualified disaster
distributions in this part.
Disaster FEMA number*

Disaster beginning date*

Disaster ending date*

DRAFT AS OF
September 13, 2021
DO NOT FILE
* See Table 1 at the end of the instructions for the FEMA number, and for disaster beginning and ending dates. If more than two
disasters, see instructions and check this box . . . . . . . . . . . . . . . . . . . . . . . . . .
(a)
Available
distributions
for this year
(see instructions)

Date first distribution made this year ▶
Date last distribution made this year ▶

Complete lines 1a through 1e first. If line 1e is zero, stop. Do not complete Part I.
1

a

.

▶

(b)
Qualified disaster
distributions for
the disasters in
item C
(see instructions)

Qualified disaster distribution limits (see instructions).
Do the following.

• Skip lines 1a through 1d. And, on line 1e, enter $100,000 times the number of disasters
you entered in item C earlier if:

• You checked 2020 in item B earlier and either you didn’t file 2020 Form 8915-E or you
only reported the coronavirus disaster on 2020 Form 8915-E, or
• You checked a year other than 2020 in item B and this is the first year you are filing a
Form 8915-F for disasters for the year checked in item B.

b
c
d

e
2
3
4
5

• Otherwise, on line 1a, enter $100,000 times the number of different qualified disasters
you have reported in item C on prior-year Forms 8915-F for disasters for the year you
checked in item B. (Include, in your disaster number, if you checked 2020 in item B,
qualified disaster(s) (other than the coronavirus) reported in Part I of 2020 Form 8915-E.)
Also, complete lines 1b through 1e
. . . . . . . . . . . . . . . .

1a

Enter the total qualified disaster distributions made to you in prior year(s) for all disasters
(except the coronavirus) for the year you checked in item B . . . . . . . . .
Subtract line 1b from line 1a . . . . . . . . . . . . . . . . . . .

1b
1c

Enter $100,000 times the number of qualified disasters, for the year checked in item B,
that you reported in item C but didn’t report in item C on a prior year’s Form 8915-F, or in
Part I of 2020 Form 8915-E if you checked 2020 in item B. Don’t count the coronavirus in
the number of qualified disasters . . . . . . . . . . . . . . . . . .

1d

Total available qualified disaster distribution amount for this year. Enter the sum of
lines 1c and 1d. If the amount on line 1e is zero, do NOT complete Part I . . . .
Enter, in column (a), distributions from retirement plans (other than IRAs) made this year
Enter, in column (a), distributions from traditional, SEP, and SIMPLE IRAs made this year
Enter, in column (a), distributions from Roth IRAs made this year . . . . . . . .

1e
2
3
4

Enter on line 5, column (a), the sum of lines 2 through 4 in column (a). If the amount on line
5, column (a):
• Is not greater than the amount on line 1e, enter on lines 2 through 5 in column (b) the
amounts from lines 2 through 5, respectively, in column (a).
• Is greater than the amount on line 1e, enter on line 5, column (b), the amount from line
1e. Enter on lines 2 through 4 in column (b) the amounts from lines 2 through 4,
respectively, in column (a) adjusted by any reasonable method so that the sum of lines
2 through 4 in column (b) equals the amount on line 5, column (b).
See instructions . . . . . . . . . . . . . . . . . . . . . .

6

7

5

Total qualified disaster distributions. Enter the amount from line 5, column (b). The 10% additional tax
(25% for SIMPLE IRAs) for early withdrawals is waived for this amount. See Parts II and III, later, for the tax
on this amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

Taxable amount. Enter the excess of the amount on line 5, column (a), over the amount on line 6. Report
this excess as IRA and/or pension and annuity distributions, as applicable, in accordance with the
instructions for your tax return. All or part of the amount on line 7 may be eligible for the tax benefits in Part
IV. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7
Form 8915-F (1-2022)

Page 3

Form 8915-F (1-2022)

Part II
8
9

Qualified Disaster Distributions From Retirement Plans (Other Than IRAs) for the Coronavirus and
Disaster(s) Listed in Item C

Did you enter an amount on line 2, column (b)?
No. Skip lines 8 through 11, and go to line 12.
Yes. Enter the amount from line 2, column (b) .
Enter the applicable cost of distributions, if any. See instructions . . . . . . . . . . . . .

.
.

8
9

DRAFT AS OF
September 13, 2021
DO NOT FILE
10
11

Subtract line 9 from line 8. This is the taxable amount of your other-than-IRA retirement plan qualified
disaster distributions . . . . . . . . . . . . . . . . . . . . . . . . . . .
The entire taxable amount on line 10 will be spread over 3 years unless you elect to have it taxed in this year.
If you elect NOT to spread the taxable amount over 3 years, check this box ▶
and enter the
amount from line 10 (see instructions). Otherwise, enter the amount from line 10 divided by 3.0. You
must check the box on this line if you check the box on line 22 . . . . . . . . . . . . . .

10

11

12

Enter the amount, if any, from Worksheet 2 in the instructions. This is your income for prior years from
other-than-IRA retirement plan qualified disaster distributions . . . . . . . . . . . . . .

.

12

13

Add lines 11 and 12. This is your total income this year from other-than-IRA retirement plan qualified
disaster distributions . . . . . . . . . . . . . . . . . . . . . . . . .

.

13

14

Total repayment. Enter the amount, if any, from Worksheet 3. This is your total repayment for this year of
other-than-IRA retirement plan qualified disaster distributions . . . . . . . . . . . . . . .

14

.

15

Amount subject to tax this year. Subtract line 14 from line 13. If zero or less, enter -0-. Include this
amount in the total on line 5b of this year’s Form 1040, 1040-SR, or 1040-NR. See instructions . . . .
Before you begin: Complete this year’s Form 8606, Nondeductible IRAs, if required.

Part III

Qualified Disaster Distributions From Traditional, SEP, SIMPLE, and Roth IRAs for the Coronavirus and
Disaster(s) Listed in Item C

16

Did you enter an amount on line 3, column (b), or line 4, column (b)?
Yes. Go to line 17.
No. Skip lines 17 through 22, and go to line 23.

17

Did you receive a qualified disaster distribution from a traditional, SEP, SIMPLE, or Roth IRA that is required
to be reported on this year’s Form 8606?
Yes. Go to line 18.
No. Skip lines 18 and 19, and go to line 20.
Enter the amount, if any, from this year’s Form 8606, line 15b. But if you are entering amounts here and on
other Forms 8915-F for this year, only enter on line 18 the amount on Form 8606, line 15b, attributable to
Form 8915-F distributions for this form. See the instructions for Form 8606, line 15b
. . . . . . .
Enter the amount, if any, from this year’s Form 8606, line 25b. But if you are entering amounts here and on
other Forms 8915-F for this year, only enter on line 19 the amount on Form 8606, line 25b, attributable to
Form 8915-F distributions for this form. See the instructions for Form 8606, line 25b
. . . . . . .

18
19

15

18
19

20

Enter the amount from line 3, column (b), if any. Don’t include on line 20 any amounts reported on Form
8606 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21
22

Add lines 18, 19, and 20. This is the taxable amount of your IRA-retirement-plan qualified disaster distributions
The entire taxable amount on line 21 will be spread over 3 years unless you elect to have it taxed in this year.
If you elect NOT to spread the taxable amount over 3 years, check this box ▶
and enter the
amount from line 21 (see instructions). Otherwise, enter the amount from line 21 divided by 3.0. You
must check the box on this line if you check the box on line 11 . . . . . . . . . . . . . .

23

Enter the amount, if any, from Worksheet 4 in the instructions. This is your income for prior years from IRAretirement-plan qualified disaster distributions . . . . . . . . . . . . . . . . . . . .

23

24

Add lines 22 and 23. This is your total income this year from IRA-retirement-plan qualified disaster
distributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24

25

Total repayment. Enter the amount, if any, from Worksheet 5. This is your total repayment for this year of
IRA-retirement-plan qualified disaster distributions . . . . . . . . . . . . . . . . . .

25

26

Amount subject to tax. Subtract line 25 from line 24. If zero or less, enter -0-. Include this amount in the
total on line 4b of this year’s Form 1040, 1040-SR, or 1040-NR. See instructions . . . . . . . . .

26

20
21

22

Form 8915-F (1-2022)

Page 4

Form 8915-F (1-2022)

Before you begin: Complete this year’s Form 8606, Nondeductible IRAs, if required.

Part IV

Qualified Distributions for the Purchase or Construction of a Main Home in the Area of Disaster(s)
Listed in Item C
Caution: Complete Part IV if, this year, you received a qualified distribution (as defined in the instructions) for a disaster listed in
item C earlier. If you repay the distribution, in whole or in part, after this year, see the instructions. For the applicability of Part IV
to other years for disasters listed in item C, see the instructions.

DRAFT AS OF
September 13, 2021
DO NOT FILE
}
Disaster FEMA number*

Disaster beginning date*

Disaster ending date*

* See Table 1 at the end of the instructions for the FEMA number, and for disaster beginning and ending dates.
Date first distribution received this year ▶

27

28

29
30

31

32

Date last distribution received this year ▶

Did you receive a qualified distribution from a traditional, SEP, SIMPLE, or Roth IRA that is required to be
reported on this year’s Form 8606?
Yes. Complete lines 28 through 32 only if you also had qualified distributions not required to be
reported on this year’s Form 8606; otherwise, stop here.

No. Go to line 28.
Enter the total amount of qualified distributions you received this year for the purchase or construction of a
main home. Don’t include any amounts reported on this year’s Form 8606. Also, don’t include any
distributions you reported on line 8 or 20, or on other Forms 8915 for this year, if any . . . . . . .
Enter the applicable cost of distributions, if any. See instructions . . . . . . . . . . . . . .
Subtract line 29 from line 28 . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made. See instructions for allowable repayments. Don’t
include any repayments treated as rollovers on this year’s Form 8606. See instructions . . . . . . .
Taxable amount. Subtract line 31 from line 30. If the distribution is:
• From an IRA, include this amount in the total on line 4b of this year’s Form 1040, 1040-SR, or
1040-NR.
. .
• From a retirement plan (other than an IRA), include this amount in the total on line 5b of this
year’s Form 1040, 1040-SR, or 1040-NR.
Note: You may be subject to an additional tax on the amount on line 32. See instructions.

28
29
30

31

32

Form 8915-F (1-2022)