8915-D Qualified 2019 Disaster Retirement Plan Distributions an

Version A, Cycle 2

Form

8915-D

Qualified 2019 Disaster Retirement
Plan Distributions and Repayments

OMB No. 1545-0074

2022

Go to www.irs.gov/Form8915D for instructions and the latest information.
For coronavirus-related distributions, see Form 8915-F.
Attach to 2022 Form 1040, 1040-SR, or 1040-NR.

Department of the Treasury
Internal Revenue Service

Attachment
Sequence No. 915
Your social security number

Name. If married, file a separate form for each spouse required to file 2022 Form 8915-D. 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 if You Are Filing City, town or post office, state, and ZIP code. If you have a foreign address, also complete the spaces below. See
If this is an amended
instructions.
This Form by Itself
return, check here
and Not With Your
Tax Return
Foreign country name
Foreign province/state/county
Foreign postal code

Part I
1
2
3
4a
b
5a
b
6
7

Qualified 2019 Disaster Distributions From Retirement Plans (Other Than IRAs)
1
2
3

Enter the amount, if any, from your 2020 Form 8915-D, line 11. If you checked the box on that line, enter -0Enter the amount, if any, from your 2021 Form 8915-D, line 11. If you checked the box on that line, enter -0Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the amount, if any, from your 2021 Form 8915-D, line 19 . . . . . .
4a
Enter the amount, if any, from your 2021 Form 8915-D, line 14 . . . . . .
4b
Subtract line 4b from line 4a. If zero or less, enter -0-. This is your excess
repayment from 2021 . . . . . . . . . . . . . . . . . . .
5a
Enter the amount from line 5a that you have already carried back to a prior year . .
5b
Subtract line 5b from line 5a . . . . . . . . . . . . . . . . . . . . . . . . .

INTERNAL USE ONLY
DRAFT AS OF
April 26, 2022
6

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. Don’t use this form to report
repayments of qualified disaster distributions for disasters other than qualified 2019 disasters. See instructions

8
9

7
8

Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2022. Subtract line 8 from line 3. If zero or less, enter -0-. Include this amount in
the total on 2022 Form 1040, 1040-SR, or 1040-NR, line 5b . . . . . . . . . . . . . . .

Part II
10
11
12
13a
b
14a
b
15
16

17
18

Enter the amount, if any, from your 2020 Form 8915-D, line 26. If you checked the box on that line, enter -0Enter the amount, if any, from your 2021 Form 8915-D, line 27. If you checked the box on that line, enter -0Add lines 10 and 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the amount, if any, from your 2021 Form 8915-D, line 35 . . . . . .
13a
Enter the amount, if any, from your 2021 Form 8915-D, line 30 . . . . . .
13b
Subtract line 13b from line 13a. If zero or less, enter -0-. This is your excess
repayment from 2021 . . . . . . . . . . . . . . . . . . .
14a
Enter the amount from line 14a that you have already carried back to a prior year .
14b
Subtract line 14b from line 14a . . . . . . . . . . . . . . . . . . . . . . . .
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. Don’t use this form to report
repayments of qualified disaster distributions for disasters other than qualified 2019 disasters. See instructions
Add lines 15 and 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2022. Subtract line 17 from line 12. 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

9

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

10
11
12

15

16
17
18

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. 73793G

Form 8915-D (2022)