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 2017 Form 1040, 2017 Form 1040A, or 2017 Form 1040NR.

OMB No. 1545-0074

 2017

Attachment 

Sequence No. 915

Name. If married, file a separate form for each spouse required to file 2017 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) 

Complete this part only if you have qualified 2016 disaster distributions in 2017 and the total of your qualified 2016 disaster 

distributions in 2016, if any, was less than $100,000. See instructions.

Complete line 1 first. Then complete lines 2 through 5 of one 

column before going to the next column.

(a) 

Total distributions 

in 2017

(b) 

Qualified 2016 

disaster distributions 

 (see instructions) 

(c) 

Allocation of 

column (b) 

(see instructions)

1 

 

Enter in columns (b) and (c) the amount, if any, from your 2016 Form 

8915A, line 4, column (b). If 2016 Form 8915A wasn’t filed, enter 

-0-. If this amount is $100,000 or more, do not complete this part, 

you have no qualified 2016 disaster distributions in 2017 . . .

2 Distributions from retirement plans (other than IRAs) made in 2017 .

3 Distributions from traditional, SEP, and SIMPLE IRAs made in 2017 .

4 Distributions from Roth IRAs made in 2017 . . . . . . .

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

column (c) only if line 5, column (b), is more than $100,000 . . .

6 Subtract line 1 in column (c) from $100,000 . . . . . . .

7 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 unless you also are filing Form 8915B.

If you are filing Form 8915B, leave line 7 blank . . . . . . . . . . . . . . . . . . . 7

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

8 Did you enter an amount on line 2, column (b)?

No. Skip lines 8 through 11, and go to line 12.

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

from line 2, column (b) . . . . . . . . . . . . . . . . . . . . . . . . . 8

9 Enter the applicable cost of distributions, if any. See instructions . . . . . . . . . . . . . . 9

10 Subtract line 9 from line 8 . . . . . . . . . . . . . . . . . . . . . . . . . 10

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

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 . . . . . . . . . . . . . . . . . . . . . . . . 11

12 Enter the amount, if any, from your 2016 Form 8915A, line 9. If you checked the box on that line, 

enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

13 Add lines 11 and 12 . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

14 Enter the amount, if any, from your 2016 Form 8915A, line 10 . . . . . . 14

15 Enter the amount, if any, from your 2016 Form 8915A, line 9 . . . . . . 15

16 Subtract line 15 from line 14. If zero or less, enter -0- . . . . . . . . . . . . . . . . . 16

17 Enter the total amount of any repayments you made before filing your 2017 tax return. But do not include 

repayments made later than the due date (including extensions) for that return. See instructions . . . . . 17

18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

19 Amount subject to tax in 2017. Subtract line 18 from line 13. If zero or less, enter -0-. Include 

this amount in the total on 2017 Form 1040, line 16b; 2017 Form 1040A, line 12b; or 2017 Form 1040NR, 

line 17b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 71167K Form 8915A (2017)
Form 8915A (2017) Page 2

Before you begin: Complete 2017 Form 8606, Nondeductible IRAs, if required.

Part III Qualified 2016 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 2016 disaster distribution from a traditional, SEP, SIMPLE, or Roth IRA that is 

required to be reported on 2017 Form 8606?

Yes. Go to line 22.

No. Skip lines 22 through 23, and go to line 24.

22 Enter the amount, if any, from 2017 Form 8606, line 15b . . . . . . . . . . . . . . . . 22

23 Enter the amount, if any, from 2017 Form 8606, line 25b . . . . . . . . . . . . . . . . 23

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 2017 Form 8606 . . . . . . . . . . . . 24

25 Add lines 22, 23, and 24 . . . . . . . . . . . . . . . . . . . . . . . . . . 25

26 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 . . . . . . . . . . . . . . . . . . . . . . . . 26

27 Enter the amount, if any, from your 2016 Form 8915A, line 17. If you checked the box on that line, enter -0- . . . 27

28 Add lines 26 and 27 . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

29 Enter the amount, if any, from your 2016 Form 8915A, line 18 . . . . . . 29

30 Enter the amount, if any, from your 2016 Form 8915A, line 17 . . . . . . 30

31 Subtract line 30 from line 29. If zero or less, enter -0- . . . . . . . . . . . . . . . . . 31

32 Enter the total amount of any repayments you made before filing your 2017 tax return. But do not include 

repayments made later than the due date (including extensions) for that return. See instructions . . . . . 32

33 Add lines 31 and 32 . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

34 Amount subject to tax in 2017. Subtract line 33 from line 28. If zero or less, enter -0-. Include this amount in 

the total on 2017 Form 1040, line 15b; 2017 Form 1040A, line 11b; or 2017 Form 1040NR, line 16b . . . . 34

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.

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self-employed 

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Phone no.

Form 8915A (2017)