Form

Department of the Treasury

Internal Revenue Service

Qualified Hurricane Retirement

Plan Distributions and Repayments

OMB No. 1545-0074

© Attach to Form 1040, Form 1040A, or Form 1040NR.

Attachment

Sequence No. 156

Total Distributions From All Retirement Plans (Including IRAs)

2

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

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Part I

For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 37726T Form 8915 (2006)

8915

Name. If married, file a separate form for each spouse required to file Form 8915. See instructions. Your social security number

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Part II Qualified Hurricane Distributions From Retirement Plans (other than IRAs)

Add lines 11 and 12

Enter the amount, if any, from your 2005 Form 8915, line 9. If you checked the box on that line, 

enter -0-

© 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)

City, town or post office, state, and ZIP code

Complete lines 1 through 5 of one column

before going to the next column

(a)

Total distributions

for 2006

(b)

Qualified distributions

(see instructions)

(c)

Allocation of column (b)

(see instructions)

Distributions from retirement plans 

3 Distributions from traditional, SEP, and SIMPLE IRAs 

4 Distributions from Roth IRAs 

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

Complete column (c) only if line 5, column (b), is more than 

$100,000 100,000

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

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

10 Subtract line 9 from line 8 10

11

11

13

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

and enter the amount from line 10. You must check this box if you check

the box on line 26. Otherwise, divide line 10 by 3.0 

Apt. no.

00

2006

Complete this part only if you have qualified hurricane distributions for 2006 and the total of your qualified

hurricane distributions for 2005, if any, was less than $100,000 (see instructions).

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

2005 Form 8915, line 4, column (b). If this amount is

$100,000 or more, do not complete this part, you have no 

qualified hurricane distributions for 2006 

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)

14 Enter the amount, if any, from your 2005 Form 8915, line 10 14

15 Enter the amount, if any, from your 2005 Form 8915, 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 2006 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

Amount subject to tax in 2006. Subtract line 18 from line 13. If zero or less, enter -0-. Include 

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

line 17b

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6 Subtract line 1 (in columns (b) and (c)) from $100,000 
Qualified Hurricane Distributions From Traditional, SEP, SIMPLE, and Roth IRAs

20 Did you enter an amount on line 3, column (b), or line 4, column (b)?

Form 8915 (2006)

Part III

EIN ©

Preparer’s SSN or PTIN

Paid

Preparer’s

Use Only

Preparer’s

signature

Check if self- © employed ©

© Firm’s name (or yours

if self-employed),

address, and ZIP code Phone no. ( )

Form 8915 (2006) Page 2

Yes. Go to line 21.

No. Skip lines 21 through 26, and go to line 27.

Did you receive a qualified hurricane distribution from a traditional, SEP, SIMPLE, or Roth IRA

that is required to be reported on Form 8606?

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

25 Add lines 22, 23, and 24

26

27

31

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

and enter the amount from line 25. You must check this box if you checked

the box on line 11. Otherwise, divide line 25 by 3.0

28 Add lines 26 and 27

Please

Sign

Here

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.

Your signature Date

Signature. Complete only if you are filing this form by itself and not with your tax return.

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

Yes. Go to line 22.

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

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

If you completed line 3, column (c), enter that amount. Otherwise, enter the amount from line 3, 

column (b). Do not include any amounts reported on Form 8606

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24

26

Enter the amount, if any, from your 2005 Form 8915, line 17. If you checked the box on that line, 

enter -0-

27

25

28

29 Enter the amount, if any, from your 2005 Form 8915, line 18 29

30 Enter the amount, if any, from your 2005 Form 8915, line 17 30

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

Enter the total amount of any repayments you made before filing your 2006 tax return. But do

not include repayments made later than the due date (including extensions) for that return.

See instructions

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33 Add lines 31 and 32 33

Amount subject to tax in 2006. Subtract line 33 from line 28. If zero or less, enter -0-. Include 

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

line 16b

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