2120 Multiple Support Declaration

Caution: DRAFT FORM
This is an advance proof copy of an IRS tax form.
It is subject to change and OMB approval before it
is officially released. You can check the scheduled
release date on our web site (www.irs.gov).
If you have any comments on this draft form, you can
submit them to us on our web site. Include the word
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your comments, please send them to us within 30
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Date

Form

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8915, PAGE 1 OF 2
MARGINS; TOP 13mm (1⁄ 2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE, WRITING, SUB. 20
INK: BLACK
FLAT SIZE: 216mm (81⁄ 2 ") 3 279mm (11")
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

8915

Action

©

Revised proofs
requested

OMB No. 1545-0074

©

2006
Attachment
Sequence No.

Attach to Form 1040, Form 1040A, or Form 1040NR.

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

156

Your social security number

Home address (number and street, or P.O. box if mail is not delivered to your home)

Apt. no.

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Fill in Your Address Only
If You are Filing This
Form by Itself and Not
With Your Tax Return

Signature

O.K. to print

Qualified Hurricane Retirement
Plan Distributions and Repayments

Department of the Treasury
Internal Revenue Service

Part I

Date

City, town or post office, state, and ZIP code

Total Distributions From All Retirement Plans (Including IRAs)
Complete this part only if you have qualified hurricane distributions for 2006 and the total of your qualified
hurricane distributions for 2005, if any, was less than $100,000 (see instructions).
Complete lines 1 through 5 of one column
before going to the next column

(a)
Total distributions
for 2006

1

2
3
4
5

6
7

(b)
Qualified distributions
(see instructions)

Enter in columns (b) and (c) the amount, if any, from your
2005 Form 8915, line 4, column (b). If this amount is
$100,000 or more, do not complete this part, you have no
qualified hurricane distributions for 2006
Distributions from retirement plans
Distributions from traditional, SEP, and SIMPLE IRAs
Distributions from Roth IRAs
Totals. Add lines 1 through 4 in columns (a) and (b).
Complete column (c) only if line 5, column (b), is more than
$100,000
Subtract line 1 (in columns (b) and (c)) from $100,000
If you completed column (c), enter the excess of the amount on line 5, column (a), over the
amount on line 6, column (c). Otherwise, enter the excess of the amount on line 5, column (a)
over the amount on line 6, column (b). Report these distributions under the normal rules in
accordance with the instructions for your tax return

(c)
Allocation of column (b)
(see instructions)

100,000

00

8915

(2006)

7

Part II Qualified Hurricane Distributions From Retirement Plans (other than IRAs)
8

9
10
11

12
13
14
15
16
17

18
19

Did you enter an amount on line 2, column (b)?
No. Skip lines 8 through 11, and go to line 12.
Yes. If you completed line 2, column (c), enter that amount. Otherwise, enter the amount
from line 2, column (b)
Enter the applicable cost of distributions, if any. See instructions
Subtract line 9 from line 8
If you elect NOT to spread the taxable amount over 3 years, check this box ©
and enter the amount from line 10. You must check this box if you check
the box on line 26. Otherwise, divide line 10 by 3.0

8
9
10

Enter the amount, if any, from your 2005 Form 8915, line 9. If you checked the box on that line,
enter -0Add lines 11 and 12
14
Enter the amount, if any, from your 2005 Form 8915, line 10

12
13

15
Enter the amount, if any, from your 2005 Form 8915, line 9
Subtract line 15 from line 14. If zero or less, enter -0Enter the total amount of any repayments you made before filing your 2006 tax return. But do
not include repayments made later than the due date (including extensions) for that return. See
instructions
Add lines 16 and 17
Amount subject to tax in 2006. Subtract line 18 from line 13. If zero or less, enter -0-. Include
this amount in the total on Form 1040, line 16b; Form 1040A, line 12b; or Form 1040NR,
line 17b

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

Cat. No. 37726T

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Form

7
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8915, PAGE 2 OF 2
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 8915 (2006)

Page

2

Before you begin: Complete Form 8606, Nondeductible IRAs, if required.

Part III
20

Qualified Hurricane Distributions From Traditional, SEP, SIMPLE, and Roth IRAs

28

Did you enter an amount on line 3, column (b), or line 4, column (b)?
Yes. Go to line 21.
No. Skip lines 21 through 26, and go to line 27.
Did you receive a qualified hurricane distribution from a traditional, SEP, SIMPLE, or Roth IRA
that is required to be reported on Form 8606?
Yes. Go to line 22.
No. Skip lines 22 through 23, and go to line 24.
Enter the amount, if any, from Form 8606, line 15b
Enter the amount, if any, from Form 8606, line 25b
If you completed line 3, column (c), enter that amount. Otherwise, enter the amount from line 3,
column (b)
Add lines 22, 23, and 24
If you elect NOT to spread the taxable amount over 3 years, check this box ©
and enter the amount from line 25. You must check this box if you checked
the box on line 11. Otherwise, divide line 25 by 3.0
Enter the amount, if any, from your 2005 Form 8915, line 17. If you checked the box on that line,
enter -0Add lines 26 and 27

29

Enter the amount, if any, from your 2005 Form 8915, line 18

30
31
32

30
Enter the amount, if any, from your 2005 Form 8915, line 17
Subtract line 30 from line 29. If zero or less, enter -0Enter the total amount of any repayments you made before filing your 2006 tax return. But do
not include repayments made later than the due date (including extensions) for that return.
See instructions

33
34

Add lines 31 and 32
Amount subject to tax in 2006. Subtract line 33 from line 28. If zero or less, enter -0-. Include
this amount in the total on Form 1040, line 15b; Form 1040A, line 11b; or Form 1040NR,
line 16b

21

22
23
24
25
26

27

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25

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Signature. Complete only if you are filing this form by itself and not with your tax return.

Please
Sign
Here

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.

Your signature

Paid
Preparer’s
Use Only

Preparer’s
signature

©

Firm’s name (or yours
if self-employed),
address, and ZIP code

Date

©

Check if selfemployed ©
EIN

Preparer’s SSN or PTIN

©

Phone no.

(

)
Form

8915

(2006)