Form 8915A

Department of the Treasury 

Internal Revenue Service 

Qualified 2016 Disaster Retirement 

Plan Distributions and Repayments

▶ Go to www.irs.gov/Form8915 for instructions and the latest information.

▶ Attach to 2016 Form 1040, 2016 Form 1040A, or 2016 Form 1040NR; or Form 1040X, if applicable.

OMB No. 1545-0074

 2016

Attachment 

Sequence No. 915

Name. If married, file a separate form for each spouse required to file 2016 Form 8915A. 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). If this is an amended 

return, check here ▶

Foreign country name Foreign province/state/county Foreign postal code

Part I Total Distributions From All Retirement Plans (Including IRAs) (See instructions.)

Complete lines 1 through 4 of one column 

before going to the next column.

(a) 

Total distributions 

in 2016

(b) 

Qualified 

2016 disaster 

distributions 

made in 2016 

(see instructions) 

(c) 

Allocation of 

column (b) 

(see instructions)

1 Distributions from retirement plans (other than IRAs) .

2 Distributions from traditional, SEP, and SIMPLE IRAs 

3 Distributions from Roth IRAs . . . . . . . .

4 Totals. Add lines 1 through 3 in columns (a) and (b). 

Complete column (c) only if line 4, column (b), is more 

than $100,000 . . . . . . . . . . . . .

5 If you completed column (c), enter the excess of the amount on line 4, column (a), over $100,000. 

Otherwise, enter the excess of the amount on line 4, column (a), over the amount on line 4, 

column (b). Report these distributions under the normal rules in accordance with the instructions 

for your tax return . . . . . . . . . . . . . . . . . . . . . . . . . . 5 

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

6 If you completed line 1, column (c), enter that amount. Otherwise, enter the amount from line 1, 

column (b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Enter the applicable cost of distributions, if any. See instructions . . . . . . . . . . 7

8 Subtract line 7 from line 6 . . . . . . . . . . . . . . . . . . . . . . . 8

9 If you elect NOT to spread the taxable amount over 3 years, check this box ▶

and enter the amount from line 8 (see instructions). You must check this box if you check the

box on line 17. Otherwise, divide line 8 by 3.0 . . . . . . . . . . . . . . . . . 9

10 Enter the total amount of any repayments you made before filing your 2016 tax return. But don’t 

include repayments made later than the due date (including extensions) for that return. 

See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

11 Amount subject to tax in 2016. Subtract line 10 from line 9. If zero or less, enter -0-. Include

this amount in the total on 2016 Form 1040, line 16b; 2016 Form 1040A, line 12b; or 2016 Form

1040NR, line 17b; or Form 1040X, line 1B, if applicable . . . . . . . . . . . . . . 11

For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 71167K Form 8915A (2016)
Form 8915A (2016) Page 2

Before you begin: Complete 2016 Form 8606, Nondeductible IRAs, if required.

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

12 Did you receive a qualified 2016 disaster distribution from a traditional, SEP, SIMPLE, or Roth

IRA that is required to be reported on 2016 Form 8606? 

Yes. Go to line 13. No. Skip lines 13 and 14, and go to line 15.

13 Enter the amount, if any, from 2016 Form 8606, line 15b . . . . . . . . . . . . . 13

14 Enter the amount, if any, from 2016 Form 8606, line 25b . . . . . . . . . . . . . 14

15 If you completed line 2, column (c), enter that amount. Otherwise, enter the amount from line 2, 

column (b), if any. Don’t include on line 15 any amounts reported on 2016 Form 8606 . . . 15

16 Add lines 13, 14, and 15 . . . . . . . . . . . . . . . . . . . . . . . . 16

17 If you elect NOT to spread the taxable amount over 3 years, check this box ▶

and enter the amount from line 16 (see instructions). You must check this box if you checked the

box on line 9. Otherwise, divide line 16 by 3.0 . . . . . . . . . . . . . . . . . 17

18 Enter the total amount of any repayments you made before filing your 2016 tax return. But don’t 

include any repayments made later than the due date (including extensions) for that return. 

See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

19 Amount subject to tax in 2016. Subtract line 18 from line 17. If zero or less, enter -0-. Include

this amount in the total on 2016 Form 1040, line 15b; 2016 Form 1040A, line 11b; or 2016 Form

1040NR, line 16b; or Form 1040X, line 1B, if applicable . . . . . . . . . . . . . . 19

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 address ▶

Firm’s EIN ▶

Phone no.

Form 8915A (2016)