U.S. Individual Income Tax Return Forms

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Form

Qualified 2017 Disaster Retirement
Plan Distributions and Repayments

8915-B
▶

Department of the Treasury
Internal Revenue Service

OMB No. 1545-0074

2020

Go to www.irs.gov/Form8915B for instructions and the latest information.
▶ For coronavirus-related distributions, see Form 8915-E.
▶ Attach to 2020 Form 1040, 1040-SR, or 1040-NR.

Attachment
Sequence No. 915
Your social security number

Name. If married, file a separate form for each spouse required to file 2020 Form 8915-B. See instructions.

DRAFT AS OF
November 6, 2020
DO NOT FILE
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

Part I

Apt. no.

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

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 2018 Form 8915B, line 11. If you checked the box on that line,
enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2
3
4
5

2
Enter the amount, if any, from your 2019 Form 8915-B, line 8 . . . . . .
Enter the amount, if any, from your 2019 Form 8915-B, line 3 . . . . . .
3
Subtract line 3 from line 2. If zero or less, enter -0- . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made before filing your 2020 tax return. But do not
include repayments made later than the due date (including extensions) for that return or after the 3year cutoff date. Do not use this form to report repayments of qualified 2016, 2018, 2019, or 2020
disaster distributions. See instructions . . . . . . . . . . . . . . . . . . . . .

6
7

Add lines 4 and 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2020. Subtract line 6 from line 1. If zero or less, enter -0-. Include this
amount in the total on 2020 Form 1040, 1040-SR, or 1040-NR, line 5b . . . . . . . . . . .

Part II
8

1

4

5
6
7

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

Enter the amount, if any, from your 2018 Form 8915B, line 26. If you checked the box on that line,
enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9
10
11

Enter the amount, if any, from your 2019 Form 8915-B, line 17
Enter the amount, if any, from your 2019 Form 8915-B, line 12
Subtract line 10 from line 9. If zero or less, enter -0- . . . .

12

Enter the total amount of any repayments you made before filing your 2020 tax return. But do not
include repayments made later than the due date (including extensions) for that return or after the 3year cutoff date. Do not use this form to report repayments of qualified 2016, 2018, 2019, or 2020
disaster distributions. If, in 2017, you reported certain qualified 2017 disaster distributions on 2017
Form 8915-A, you must report repayments of those distributions on Form 8915-A. See instructions .

13
14

Add lines 11 and 12 . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amount subject to tax in 2020. Subtract line 13 from line 8. If zero or less, enter -0-. Include this
amount in the total on 2020 Form 1040, 1040-SR, or 1040-NR, line 4b . . . . . . . . . . .

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Paid
Preparer
Use Only

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8

11

12
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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

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Your signature

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

Date
Check
if
self-employed
Firm’s EIN

PTIN

▶

Phone no.
Cat. No. 71180D

Form 8915-B (2020)