8915-C Qualified 2018 Disaster Retirement Plan Distributions an

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Form

8915-C

Department of the Treasury
Internal Revenue Service

Qualified 2018 Disaster Retirement
Plan Distributions and Repayments

OMB No. 1545-0074

2023

Attach to 2023 Form 1040, 1040-SR, or 1040-NR.
Go to www.irs.gov/Form8915C for instructions and the latest information.
For coronavirus-related distributions, see Form 8915-F.

Attachment
Sequence No. 915
Your social security number

Name. If married, file a separate form for each spouse required to file 2023 Form 8915-C. See instructions.

TREASURY/IRS
AND OMB USE
ONLY DRAFT
July 27, 2023
DO NOT FILE
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
1a
b
2a
b
3
4

5

b
8
9

10

Foreign postal code

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

Enter the amount, if any, from your 2022 Form 8915-C, line 6 . . . . . . .
Enter the amount, if any, from your 2022 Form 8915-C, line 1 . . . . . . .
Subtract line 1b from line 1a. If zero or less, enter -0-. This is your excess repayment
from 2022 . . . . . . . . . . . . . . . . . . . . . . .

1a
1b

2a
Enter the amount from line 2a that you have already carried back to a prior year .
2b
Subtract line 2b from line 2a . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made in 2023 that were not included on your 2022 Form
8915-C. But don’t include repayments made 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

4

Add lines 3 and 4. This amount can be carried back to reduce the amount subject to tax in a prior year. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part II
6a
b
7a

Foreign province/state/county

If this is an amended
return, check here .

5

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

Enter the amount, if any, from your 2022 Form 8915-C, line 13 .
Enter the amount, if any, from your 2022 Form 8915-C, line 8 . .
Subtract line 6b from line 6a. If zero or less, enter -0-. This
repayment from 2022 . . . . . . . . . . . . . .

.
.
is
.

. . . .
. . . .
your excess
. . . .

6a
6b

7a
Enter the amount from line 7a that you have already carried back to a prior year .
7b
Subtract line 7b from line 7a . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made in 2023 that were not included on your 2022 Form
8915-C. But don’t include any repayments made 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 8 and 9. This amount can be carried back to reduce the amount subject to tax in a prior year. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Form 8915-C (2023)