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Form by Itself and Not: 8915- D Qualified (IRS)

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Form
8915-
D
Department of the Treasury
Internal Revenue Service
Qualified 2019 Disaster Retirement
Plan Distributions and Repayments
▶
Go to www.irs.gov/Form8915D for instructions and the latest information.
▶
Attach to 2019 Form 1040, 1040-SR, or 1040-NR.
OMB No. 1545-0074
2019
Attachment
Sequence No.
915
Name. If married, file a separate form for each spouse required to file 2019 Form 8915-D. See instructions. Your social security number
Fill in Your Address Only
if You Are Filing This
Form by Itself and Not
With Your Tax Return
▲
Home address (number and street, or P.O. box if mail is not delivered to your home) Apt. no.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete the
spaces below (see instructions).
If this is an amended
return, check here
▶
Foreign country name Foreign province/state/county Foreign postal code
Before you begin:
• See Table 1 in the instructions for the list of qualified 2019 disasters.
• If you completed Part I of 2019 Form 8915-C, Qualified 2018 Disaster Retirement Plan Distributions and Repayments, see
Column (a) in the 2019 Instructions for Form 8915-D to figure the amounts for Part I, column (a), below.
• If you are reporting distributions in Part I for more than one qualified 2019 disaster, see the instructions to determine whether you
should use Worksheet 2 to figure the amounts to enter in Part I, column (b), below. If you must use Worksheet 2, check this box.
▶
Part I
Total Distributions From All Retirement Plans (Including IRAs) (See instructions.)
▲
!
CAUTION
A distribution can’t be a qualified disaster distribution unless it is
made on or after the disaster period begins.
Disaster name
Complete lines 1 through 4 of one column
before going to the next column.
(a)
Total available distributions
in 2019
(see instructions)
(b)
Qualified 2019 disaster
distributions made
in 2019
(see instructions)
(c)
Allocation of
column (b)
(see instructions)
1 Distributions from retirement plans (other than IRAs) .
Date earliest distribution made
2 Distributions from traditional, SEP, and SIMPLE IRAs
Date earliest distribution made
3 Distributions from Roth IRAs . . . . . . . .
Date earliest distribution made
4
Totals. Add lines 1 through 3 in columns (a) and (b).
If you only are reporting distributions for one 2019
disaster and the total on line 4, column (b), is more
than $100,000, complete column (c). Otherwise, leave
column (c) blank. See Column (c) in the instructions .
100,000 00
Beginning date
5
If you completed column (c), enter the excess of the amount on line 4, column (a), over $100,000.
Otherwise, enter the excess of the amount on line 4, column (a), over the amount on line 4, column
(b). Report these distributions under the normal rules in accordance with the instructions for your
tax return or, if applicable, on line 21 of this form . . . . . . . . . . . . . . . . .
5
Part II Qualified 2019 Disaster Distributions From Retirement Plans (Other Than IRAs)
6
If you completed line 1, column (c), enter that amount. Otherwise, enter the amount from line 1,
column (b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
7 Enter the applicable cost of distributions, if any. See instructions . . . . . . . . . . .
7
8 Subtract line 7 from line 6 . . . . . . . . . . . . . . . . . . . . . . . . 8
9 If you elect NOT to spread the taxable amount over 3 years, check this box
▶
and enter the
amount from line 8 (see instructions). You must check this box if you check the box on line 17.
Otherwise, divide line 8 by 3.0 . . . . . . . . . . . . . . . . . . . . . . .
9
10
Enter the total amount of any repayments you made before filing your 2019 tax return. But don’t
include repayments made later than the due date (including extensions) for that return.
Do not use this form to report repayments of qualified 2016, 2017, or 2018 disaster distributions.
See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
11
Amount subject to tax in 2019. Subtract line 10 from line 9. If zero or less, enter -0-. Include
this amount in the total on 2019 Form 1040 or 1040-SR, line 4d; or 2019 Form 1040-NR, line 17b .
11
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 73793G
Form 8915-D (2019)
Form 8915-D (2019)
Page 2
Before you begin: Complete 2019 Form 8606, Nondeductible IRAs, if required.
Part III Qualified 2019 Disaster Distributions From Traditional, SEP, SIMPLE, and Roth IRAs
12
Did you receive a qualified 2019 disaster distribution from a traditional, SEP, SIMPLE, or Roth IRA
that is required to be reported on 2019 Form 8606?
Yes. Go to line 13. No. Skip lines 13 and 14, and go to line 15.
13
Enter the amount, if any, from 2019 Form 8606, line 15b, to the extent not reported on 2019 Form
8915-C, line 22. See the 2019 Instructions for Form 8606, line 15b . . . . . . . . . . .
13
14
Enter the amount, if any, from 2019 Form 8606, line 25b, to the extent not reported on 2019 Form
8915-C, line 23. See the 2019 Instructions for Form 8606, line 25b . . . . . . . . . . .
14
15
If you completed line 2, column (c), enter that amount. Otherwise, enter the amount from line 2,
column (b), if any. Don’t include on line 15 any amounts reported on 2019 Form 8606 . . . .
15
16 Add lines 13, 14, and 15 . . . . . . . . . . . . . . . . . . . . . . . . .
16
17 If you elect NOT to spread the taxable amount over 3 years, check this box
▶
and enter the
amount from line 16 (see instructions). You must check this box if you checked the box on line 9.
Otherwise, divide line 16 by 3.0 . . . . . . . . . . . . . . . . . . . . . . .
17
18
Enter the total amount of any repayments you made before filing your 2019 tax return. But don’t
include any repayments made later than the due date (including extensions) for that return. Do not
use this form to report repayments of qualified 2016, 2017, or 2018 disaster distributions. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18
19
Amount subject to tax in 2019. Subtract line 18 from line 17. If zero or less, enter -0-. Include
this amount in the total on 2019 Form 1040 or 1040-SR, line 4b; or 2019 Form 1040-NR, line 16b .
19
Before you begin: Complete 2019 Form 8606, Nondeductible IRAs, if required.
Part IV
Qualified Distributions for the Purchase or Construction of a Main Home in Qualified 2019 Disaster Areas
Complete this section only if in 2019 you received a qualified distribution (as defined in the instructions) that
you repaid, in whole or in part, before June 18, 2020. See instructions for allowable repayments.
Caution: A distribution can’t be a qualified distribution for the purchase or construction of a main home unless it is received
no more than 180 days before the disaster period begins and no more than 30 days after the disaster period ends.
Disaster name
20
Did you receive a qualified distribution from a traditional, SEP, SIMPLE, or Roth IRA that is
required to be reported on 2019 Form 8606?
Yes. Complete lines 21 through 25 only if you also had qualified distributions not required to
be reported on 2019 Form 8606; otherwise, stop here.
No. Go to line 21.
21
Enter the total amount of qualified distributions you received in 2019 for the purchase or
construction of a main home. Don’t include any amounts reported on 2019 Form 8606. Also, don’t
include any distributions you reported on line 6 or line 15, or on 2019 Form 8915-C, line 8 or 24, if
any. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . .
21
22 Enter the applicable cost of distributions, if any. See instructions . . . . . . . . . . .
22
23 Subtract line 22 from line 21 . . . . . . . . . . . . . . . . . . . . . . . 23
24
Enter the total amount of any repayments you made. See instructions for allowable repayments.
Don’t include any repayments treated as rollovers on 2019 Form 8606. See instructions . . . .
24
25 Taxable amount. Subtract line 24 from line 23 . . . . . . . . . . . . . . . . .
25
• If the distribution is from an IRA, include this amount in the total on 2019 Form 1040 or 1040-SR, line 4b; or 2019 Form
1040-NR, line 16b.
• If the distribution is from a retirement plan (other than an IRA), include this amount in the total on 2019 Form 1040 or
1040-SR, line 4d; or 2019 Form 1040-NR, line 17b.
Note: You may be subject to an additional tax on the amount on line 25. See instructions.
Sign Here Only if You
Are Filing This Form
by Itself and Not With
Your Tax Return
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.
▲
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Date
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Preparer
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Preparer’s signature
Date
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self-employed
PTIN
Firm’s name
▶
Firm’s address
▶
Firm’s EIN
▶
Phone no.
Form
8915-D (2019)
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Form by Itself and Not: 8915- D Qualified (IRS)

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Completed 7 February 2021

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