8915-C Qualified 2018 Disaster RetirementPlan Distributions and

Form

8915-C

Qualified 2018 Disaster Retirement
Plan Distributions and Repayments

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Department of the Treasury
Internal Revenue Service

OMB No. 1545-0074

Go to www.irs.gov/Form8915C for instructions and the latest information.
▶ Attach to 2019 Form 1040, 1040-SR, or 1040-NR.

Name. If married, file a separate form for each spouse required to file 2019 Form 8915-C. See instructions.

2019

Attachment
Sequence No. 915
Your social security number

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

Part I

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

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

If this is an amended
return, check here ▶

Foreign postal code

Total Distributions From All Retirement Plans (Including IRAs)

Before you begin:
• Complete this part only if you have qualified 2018 disaster distributions in 2019 and the total of your qualified 2018 disaster distributions in 2018, if
any, for each disaster reported in 2019 is less than $100,000. See instructions.
• See Table 1 in the instructions for the list of qualified 2018 disasters.
• If you are reporting distributions in Part I for more than one qualified 2018 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. ▶

Complete line 1 first. Then, complete lines 2 through 5 of one column before going to the next column.
(a)
(b)
(c)
Total available Qualified 2018 Allocation of
distributions
disaster
column (b)
in 2019
distributions (see instructions)
(see instructions) made in 2019

Disaster name ▶

(see instructions)

1

If you are reporting only one disaster for 2019, enter in columns (b) and (c) the amount
described below for your situation. Otherwise, see Worksheet 2 in the instructions.
• If you did not file 2018 Form 8915-C, enter -0-.
• If you filed 2018 Form 8915-C, and the disaster for which you are reporting distributions
on this form is different from the disaster(s) for which you reported distributions on 2018
Form 8915-C, enter -0-.
• If you filed 2018 Form 8915-C, you reported distributions for only one disaster on that
form, and you are reporting distributions for that same disaster on this form, enter the
amount from your 2018 Form 8915-C, line 4, column (b).
• If you filed 2018 Form 8915-C on which you reported distributions for more than one
disaster and one of those disasters is the disaster for which you are reporting distributions
on this form, enter the amount for that disaster from line 4 of column (X) in Worksheet 2 in
the 2018 Form 8915-C instructions.
• If your situation is not described above, see Worksheet 2 in the instructions.
If you are reporting only one disaster for 2019 and the amount you are entering in
column (b) is $100,000 or more, do not complete this part; you have no qualified 2018
disaster distributions in 2019 . . . . . . . . . . . . . . . . . .

2
3
4

Distributions from retirement plans (other than IRAs) made in 2019 .
Distributions from traditional, SEP, and SIMPLE IRAs made in 2019 .
Distributions from Roth IRAs made in 2019 . . . . . . . .

5

Totals. Add lines 1 through 4 in columns (a) and (b). If line 5, column (b), is more than
$100,000 and you did not use Worksheet 2, you must complete column (c). Otherwise, leave
column (c) blank. See Column (c) in the instructions . . . . . . . . . . . .

6
7

Subtract line 1 in column (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 sum of the amounts on lines 2 through 4 in column (b). Report these distributions
under the normal rules in accordance with the instructions for your tax return or, if applicable, on Worksheet 3, line 2, in the instructions

Part II
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100,000

Qualified 2018 Disaster Distributions From Retirement Plans (Other Than IRAs)

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Did you enter an amount on line 2, column (b)?
Yes. If you completed line 2, column (c), enter that amount. Otherwise, enter the amount from line 2, column (b).
No. Skip lines 8 through 11, and go to line 12 . . . . . . . .
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 ▶

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and enter the amount from line 10
(see instructions). You must check this box if you check the box on line 26. Otherwise, divide line 10 by 3.0 . . .
Enter the amount, if any, from your 2018 Form 8915-C, line 9. If you checked the box on that line, enter -0- . . .

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Add lines 11 and 12 . . . . . . . . . . . . . . . . . . . . . . .
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see your tax return instructions.

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Cat. No. 72465B

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Form 8915-C (2019)

Page 2

Form 8915-C (2019)

Qualified 2018 Disaster Distributions From Retirement Plans (Other Than IRAs) (continued)

Part II
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Enter the amount, if any, from your 2018 Form 8915-C, line 10
. .
Enter the amount, if any, from your 2018 Form 8915-C, line 9 . . .
Subtract line 15 from line 14. If zero or less, enter -0- . . . . .
Enter the total amount of any repayments you made before filing your
made later than the due date (including extensions) for that return.
qualified 2016, 2017, or 2019 disaster distributions. See instructions .

18

Add lines 16 and 17

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14
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15
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2019 tax return. But do not include repayments
Do not use this form to report repayments of
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18

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Amount subject to tax in 2019. Subtract line 18 from line 13. 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 . . . . . . . . . . . . .
Before you begin: Complete 2019 Form 8606, Nondeductible IRAs, if required.

Part III

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Qualified 2018 Disaster Distributions From Traditional, SEP, SIMPLE, and Roth IRAs

20

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.

21

Did you receive a qualified 2018 disaster distribution from a traditional, SEP, SIMPLE, or Roth IRA that is required to be
reported on 2019 Form 8606?
Yes. Go to line 22.
No. Skip lines 22 and 23, and go to line 24.

22

Enter the amount, if any, from 2019 Form 8606, line 15b. But if you are entering amounts here and on Form 8915-D,
line 13, only enter on line 22 the amount on Form 8606, line 15b, attributable to Form 8915-C distributions. See the
instructions for Form 8606, line 15b
. . . . . . . . . . . . . . . . . . . . . . . .

22

Enter the amount, if any, from 2019 Form 8606, line 25b. But if you are entering amounts here and on
Form 8915-D, line 14, only enter on line 23 the amount on Form 8606, line 25b, attributable to Form 8915-C
distributions. See the instructions for Form 8606, line 25b . . . . . . . . . . . . . . . . . .

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24

If you completed line 3, column (c), enter that amount. Otherwise, enter the amount from line 3, column (b), if any.
Don’t include on line 24 any amounts reported on 2019 Form 8606 . . . . . . . . . . . . . . .

24

25
26

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
(see instructions). You must check this box if you check the box on line 11. Otherwise, divide line 25 by 3.0 . .

25

27
28
29

Enter the amount, if any, from your 2018 Form 8915-C, line 17. If you checked the box on that line, enter -0- .
Add lines 26 and 27 . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter the amount, if any, from your 2018 Form 8915-C, line 18
. . . . . . . . . .
29

30
31

Enter the amount, if any, from your 2018 Form 8915-C, line 17
Subtract line 30 from line 29. If zero or less, enter -0- . . .

32

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. Do not use this form to report repayments of
qualified 2016, 2017, or 2019 disaster distributions. See instructions . . . . . . . . . . . . . . .

33

Add lines 31 and 32

34

Amount subject to tax in 2019. Subtract line 33 from line 28. 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 . . . . . . . . . . . . .

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Part IV

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Qualified Distributions for the Purchase or Construction of a Main Home in Qualified 2018 Disaster Areas
Complete this part 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 the amount to enter on line 35.

Caution: A qualified distribution for the purchase or construction of a main home must be received no later than 30 days after the disaster ends.
Ending date ▶
Disaster name ▶
Date last distribution received ▶
35

Taxable amount. Enter the amount from Worksheet 3, line 6.
• 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 35. See instructions.

Your signature

Print/Type preparer’s name
Firm’s name

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Paid
Preparer
Use Only

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35

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

}

Preparer’s signature

Date

Date
Check
if PTIN
self-employed

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Firm’s EIN

Firm’s address ▶

Phone no.

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Form 8915-C (2019)