Form 8915 Qualified Hurricane Retirement Plan Distribution and Rep

Form

8915

Qualified Hurricane Retirement
Plan Distributions and Repayments

OMB No. 1545-0074

2009

Department of the Treasury
© Attach to Form 1040, Form 1040A, or Form 1040NR.
Internal Revenue Service
Name. If married, file a separate form for each spouse required to file Form 8915. See instructions.

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

Part I

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Attachment
Sequence No. 156
Your social security number
Apt. no.

Home address (number and street, or P.O. box if mail is not delivered to your home)
City, town or post office, state, and ZIP code

Qualified Hurricane Distributions From Retirement Plans (other than IRAs)

1
2

Enter the amount, if any, from your 2008 Form 8915, line 6
Enter the amount, if any, from your 2008 Form 8915, line 1

3

Subtract line 2 from line 1. If zero or less, enter -0-

.

3

4

Enter the total amount of any repayments you made in 2009. But do not include repayments made
on or before the due date (including extensions) for filing your 2008 tax return. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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 . . . . . . . . . . . . . . . . . . . . . . . . . .

5

5

Part II

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

6
7

Enter the amount, if any, from your 2008 Form 8915, line 13 .
Enter the amount, if any, from your 2008 Form 8915, line 8 .

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8

Subtract line 7 from line 6. If zero or less, enter -0-

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8

9

Enter the total amount of any repayments you made in 2009. But do not include repayments made
on or before the due date (including extensions) for filing your 2008 tax return. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9

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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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.

Sign Here Only If You
Are Filing This Form
by Itself and Not With
Your Tax Return

Paid
Preparer’s
Use Only

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6
7

©

Date

©

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

©

Your signature

©

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

Date

Check if selfemployed ©

Preparer's SSN or PTIN

EIN ©
Phone no.
Cat. No. 37726T

Form 8915 (2009)