8915-B Qualified 2017 Disaster Retirement Plan Distributions an

Qualified 2017 Disaster Retirement
Plan Distributions and Repayments

8915-B

Form

OMB No. 1545-0074

2019

▶ Go to www.irs.gov/Form8915B for instructions and the latest information.
Department of the Treasury
Attachment
▶ Attach to 2019 Form 1040, 1040-SR, or 1040-NR.
Internal Revenue Service
Sequence No. 915
Name. If married, file a separate form for each spouse required to file 2019 Form 8915-B. See instructions.
Your social security number

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

▲

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

City, town or post office, state, and ZIP code. If you have a foreign address, also complete the spaces below (see
instructions).

Foreign country name

Part I

Apt. no.

Foreign province/state/county

Foreign postal code

Qualified 2017 Disaster Distributions From Retirement Plans (Other Than IRAs)

1 Enter the amount, if any, from your 2017 Form 8915B, line 9. If you checked the box on that line, enter
-0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 Enter the amount, if any, from your 2018 Form 8915B, line 11. If you checked the box on that line,
enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
4 Enter the amount, if any, from your 2018 Form 8915B, line 18 . . . . . .
5 Enter the amount, if any, from your 2018 Form 8915B, line 13
. . . . .
5
6 Subtract line 5 from line 4. If zero or less, enter -0- . . . . . . . . . . . . . . . . .

1
2
3

6

7 Enter the total amount of any repayments you made before filing your 2019 tax return. But do not
include repayments made later than the due date (including extensions) for that return. If you repaid
amounts that previously were reported as qualified 2016 disaster distributions in 2016 or 2017 Form
8915A, Part II, file 2019 Form 8915-A to claim a repayment of those amounts. See instructions. . .
8 Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9 Amount subject to tax in 2019. Subtract line 8 from line 3. 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 . . .

Part II
10
11
12
13
14
15

7
8
9

Qualified 2017 Disaster Distributions From Traditional, SEP, SIMPLE, and Roth IRAs

Enter the amount, if any, from your 2017 Form 8915B, line 17. If you checked the box on that line, enter -0Enter the amount, if any, from your 2018 Form 8915B, line 26. If you checked the box on that line, enter -0Add lines 10 and 11 . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the amount, if any, from your 2018 Form 8915B, line 33 . . . . . .
13
Enter the amount, if any, from your 2018 Form 8915B, line 28 . . . . . .
14
Subtract line 14 from line 13. If zero or less, enter -0- . . . . . . . . . . . . . . . .

10
11
12

15

Paid
Preparer
Use Only

▲

▲

16 Enter the total amount of any repayments you made before filing your 2019 tax return. But do not
include repayments made later than the due date (including extensions) for that return. If you repaid
amounts that previously were reported as qualified 2016 disaster distributions in 2016 or 2017 Form
8915A, Part III, file 2019 Form 8915-A to claim a repayment of those amounts. See instructions . .
16
17 Add lines 15 and 16 . . . . . . . . . . . . . . . . . . . . . . . . . . .
17
18 Amount subject to tax in 2019. Subtract line 17 from line 12. 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 . . .
18
Under penalties of perjury, I declare that I have examined this form, including accompanying attachments, and to the best of my knowledge and
Sign Here Only if You
belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Are Filing This Form
by Itself and Not With
Your Tax Return
Your signature
Date
Print/Type preparer’s name
Firm’s name

▶

Firm’s address

▶

Preparer’s signature

For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions.

Date

Check
if
self-employed
Firm’s EIN

PTIN

▶

Phone no.
Cat. No. 71180D

Form 8915-B (2019)