8915-D Qualified 2019 Disaster Retirement Plan Distributions an

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Form

8915-D

Qualified 2019 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/Form8915D for instructions and the latest information.
For coronavirus-related distributions, see Form 8915-F.

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 2023 Form 8915-D. 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.

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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
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This Form by Itself
return, check here
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Part I
1
2a
b
3a
b
4
5
6
7

b
11
12
13
14

1

4

5
6

Add lines 4 and 5
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2023. Subtract line 6 from line 1. If zero or less, enter -0-. Include this amount in
the total on 2023 Form 1040, 1040-SR, or 1040-NR, line 5b . . . . . . . . . . . . . . .

Part II
8
9a
b
10a

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

Enter the amount, if any, from your 2021 Form 8915-D, line 11. If you checked the box on that line, enter -0Enter the amount, if any, from your 2022 Form 8915-D, line 8 . . . . . . .
2a
Enter the amount, if any, from your 2022 Form 8915-D, line 3 . . . . . . .
2b
Subtract line 2b from line 2a. If zero or less, enter -0-. This is your excess
repayment from 2022 . . . . . . . . . . . . . . . . . . .
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 for 2023. See instructions. Don’t use this form to report
repayments of qualified disaster distributions for disasters other than qualified 2019 disasters
. . . .

Enter the amount, if any, from your 2021 Form 8915-D, line 27. If you checked the box on that line, enter -0Enter the amount, if any, from your 2022 Form 8915-D, line 17 . . . . . .
9a
Enter the amount, if any, from your 2022 Form 8915-D, line 12 . . . . . .
9b
Subtract line 9b from line 9a. If zero or less, enter -0-. This is your excess
repayment from 2022 . . . . . . . . . . . . . . . . . . .
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 for 2023. See instructions. Don’t use this form to report
repayments of qualified disaster distributions for disasters other than qualified 2019 disasters
. . . .

Add lines 11 and 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2023. Subtract line 13 from line 8. If zero or less, enter -0-. Include this amount in
the total on 2023 Form 1040, 1040-SR, or 1040-NR, line 4b . . . . . . . . . . . . . . .

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Your Tax Return

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Preparer
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7

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

8

11

12
13
14

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Cat. No. 73793G

Form 8915-D (2023)