8915-C Qualified 2018 Disaster Retirement Plan Distributions an

Version A, Cycle 2

Form

8915-C

Department of the Treasury
Internal Revenue Service

Qualified 2018 Disaster Retirement
Plan Distributions and Repayments

OMB No. 1545-0074

2022

Go to www.irs.gov/Form8915C for instructions and the latest information.
For coronavirus-related distributions, see Form 8915-F.
Attach to 2022 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 2022 Form 8915-C. See instructions.
Home address (number and street, or P.O. box if mail is not delivered to your home)

Apt. no.

Fill in Your Address Only City, town or post office, state, and ZIP code. If you have a foreign address, also complete the spaces below.
See instructions.
if You Are Filing This
Form by Itself and Not
With Your Tax Return
Foreign country name

Part I
1
2a
b
3a
b
4
5

6
7

b
11
12

13
14

Foreign postal code

Qualified 2018 Disaster Distributions From Retirement Plans (Other Than IRAs)
1

Enter the amount, if any, from your 2020 Form 8915-C, line 11. If you checked the box on that line, enter -0Enter the amount, if any, from your 2021 Form 8915-C, line 8 . . . . . . .
2a
Enter the amount, if any, from your 2021 Form 8915-C, line 3 . . . . . . .
2b
Subtract line 2b from line 2a. If zero or less, enter -0-. This is your excess repayment
from 2021 . . . . . . . . . . . . . . . . . . . . . . .
3a
Enter the amount from line 3a that you have already carried back to a prior year .
3b
Subtract line 3b from line 3a . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made before filing your 2022 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 disaster distributions for disasters other than
qualified 2018 disasters. See instructions . . . . . . . . . . . . . . . . . . . . .
Add lines 4 and 5
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2022. Subtract line 6 from line 1. If zero or less, enter -0-. Include this amount in
the total on 2022 Form 1040, 1040-SR, or 1040-NR, line 5b . . . . . . . . . . . . . . .

4

INTERNAL USE ONLY
DRAFT AS OF
April 26, 2022

Part II
8
9a
b
10a

Foreign province/state/county

If this is an amended
return, check here .

7

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

Enter the amount, if any, from your 2020 Form 8915-C, line 27. If you checked the box on that line, enter -0Enter the amount, if any, from your 2021 Form 8915-C, line 17 . . . . . .
9a
Enter the amount, if any, from your 2021 Form 8915-C, line 12 . . . . . .
9b
Subtract line 9b from line 9a. If zero or less, enter -0-. This is your excess
repayment from 2021 . . . . . . . . . . . . . . . . . . .
10a
Enter the amount from line 10a that you have already carried back to a prior year .
10b
Subtract line 10b from line 10a . . . . . . . . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made before filing your 2022 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 disaster distributions for disasters other than
qualified 2018 disasters. See instructions . . . . . . . . . . . . . . . . . . . . .
Add lines 11 and 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2022. Subtract line 13 from line 8. If zero or less, enter -0-. Include this amount in
the total on 2022 Form 1040, 1040-SR, or 1040-NR, line 4b . . . . . . . . . . . . . . .

Sign Here Only if You
Are Filing This Form
by Itself and Not With
Your Tax Return

Paid
Preparer
Use Only

5
6

8

11

12
13
14

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.

Your signature

Print/Type preparer’s name

Date
Preparer’s signature

Date

Firm’s name

Firm’s EIN

Firm’s address

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

Check
if PTIN
self-employed

Phone no.
Cat. No. 72465B

Form 8915-C (2022)