8915-A Qualified 2016 Disaster Retirement Plan Distributions an

Form

8915-A

Qualified 2016 Disaster Retirement
Plan Distributions and Repayments
▶

Department of the Treasury
Internal Revenue Service

OMB No. 1545-0074

2020

Go to www.irs.gov/Form8915A 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-A. See instructions.
Home address (number and street, or P.O. box if mail is not delivered to your home)

Part I

▲

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

Foreign postal code

Qualified 2016 Disaster Distributions From Retirement Plans (Other Than IRAs)

1
2
3
4

Enter the amount, if any, from your 2019 Form 8915-A, line 6 . . . . . .
1
Enter the amount, if any, from your 2019 Form 8915-A, line 1 . . . . . .
2
Subtract line 2 from line 1. If zero or less, enter -0- . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made in 2020 that were not included on your 2019
Form 8915-A. But don’t include repayments made after the 3-year cutoff date. Don’t use this form to
report repayments of qualified 2017, 2018, 2019, or 2020 disaster distributions from retirement plans
(other than IRAs). See instructions . . . . . . . . . . . . . . . . . . . . . . .

5

Enter the sum of the amount from line 4 and the amount from line 3 you have not already carried back
to a prior year. This amount can be carried back to reduce the amount subject to tax in a prior year.
See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part II
6
7
8
9

10

4

5

Qualified 2016 Disaster Distributions From Traditional, SEP, SIMPLE, and Roth IRAs

Enter the amount, if any, from your 2019 Form 8915-A, line 13 . . . . .
6
Enter the amount, if any, from your 2019 Form 8915-A, line 8 . . . . . .
7
Subtract line 7 from line 6. If zero or less, enter -0- . . . . . . . . . . . . . . . . .
Enter the total amount of any repayments you made in 2020 that were not included on your 2019
Form 8915-A. But don’t include repayments made after the 3-year cutoff date. See instructions. Don’t
use this form to report repayments of qualified 2017, 2018, 2019, or 2020 disaster distributions from
IRAs, but see the Caution in Line 9 in the instructions . . . . . . . . . . . . . . . .
Enter the sum of line 9 and the amount from line 8 you have not already carried back to a prior year.
This amount can be carried back to reduce the amount subject to tax in a prior year. See instructions

8

9
10

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.

Your signature

Print/Type preparer’s name

Firm’s name

▲

▲

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

Paid
Preparer
Use Only

3

Preparer’s signature

Date

Date
Check
if
self-employed

▶

Firm’s EIN

Firm’s address ▶

Phone no.

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

Cat. No. 71167K

PTIN

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Form 8915-A (2020)