Form 8915-B 2019

Qualified 2017 Disaster Retirement 

Plan Distributions and Repayments

Department of the Treasury 

Internal Revenue Service 

▶ Go to www.irs.gov/Form8915B for instructions and the latest information.

▶ Attach to 2019 Form 1040, 1040-SR, or 1040-NR.

OMB No. 1545-0074

Attachment 

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

Fill in Your Address Only 

if You Are Filing This 

Form by Itself and Not 

With Your Tax Return ▲

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

Part I 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- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Enter the amount, if any, from your 2018 Form 8915B, line 11. If you checked the box on that line, 

enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

4 Enter the amount, if any, from your 2018 Form 8915B, line 18 . . . . . . 4

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- . . . . . . . . . . . . . . . . . 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. . . 7

8 Add lines 6 and 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

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 . . . 9

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

10 Enter the amount, if any, from your 2017 Form 8915B, line 17. If you checked the box on that line, enter -0- 10

11 Enter the amount, if any, from your 2018 Form 8915B, line 26. If you checked the box on that line, enter -0- 11

12 Add lines 10 and 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

13 Enter the amount, if any, from your 2018 Form 8915B, line 33 . . . . . . 13

14 Enter the amount, if any, from your 2018 Form 8915B, line 28 . . . . . . 14

15 Subtract line 14 from line 13. If zero or less, enter -0- . . . . . . . . . . . . . . . . 15

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

Sign Here Only if You 

Are Filing This Form 

by Itself and Not With 

Your Tax Return

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 ▲Date

Paid 

Preparer 

Use Only

Print/Type preparer’s name Preparer’s signature Date Check if 

self-employed 

PTIN

Firm’s name ▶ Firm’s EIN ▶

Firm’s address ▶ Phone no.

For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 71180D Form 8915-B (2019)