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Form 8915A

Department of the Treasury 

Internal Revenue Service 

Qualified 2016 Disaster Retirement 

Plan Distributions and Repayments

▶ Go to www.irs.gov/Form8915A for instructions and the latest information.

▶ Attach to 2018 Form 1040 or 2018 Form 1040NR.

OMB No. 1545-0074

 2018

Attachment 

Sequence No. 915

Name. If married, file a separate form for each spouse required to file 2018 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 Qualified 2016 Disaster Distributions From Retirement Plans (Other Than IRAs)

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

enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Enter the amount, if any, from your 2017 Form 8915A, 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 2017 Form 8915A, line 18 . . . . . . 4

5 Enter the amount, if any, from your 2017 Form 8915A, 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 2018 tax return. But do not include 

repayments made later than the due date (including extensions) for that return. If you are making repayments 

of amounts in 2017 Form 8915B, line 8, file 2018 Form 8915B to claim a repayment of those amounts. See 

instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

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

9 Amount subject to tax in 2018. Subtract line 8 from line 3. If zero or less, enter -0-. Include 

this amount in the total on 2018 Form 1040, line 4b; or 2018 Form 1040NR, line 17b . . . . . . . . 9

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

10 Enter the amount, if any, from your 2016 Form 8915A, line 17. If you checked the box on that line, enter -0- . . . 10

11 Enter the amount, if any, from your 2017 Form 8915A, 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 2017 Form 8915A, line 33 . . . . . . 13

14 Enter the amount, if any, from your 2017 Form 8915A, 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 2018 tax return. But do not include 

repayments made later than the due date (including extensions) for that return. If you are making repayments 

of amounts in 2017 Form 8915B, line 16, file 2018 Form 8915B to claim a repayment of those amounts. See 

instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

17 Add lines 15 and 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

18 Amount subject to tax in 2018. Subtract line 17 from line 12. If zero or less, enter -0-. Include this amount in 

the total on 2018 Form 1040, line 4b; or 2018 Form 1040NR, line 17b. . . . . . . . . . . . . 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 address ▶

Firm’s EIN ▶

Phone no.

For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 71167K Form 8915A (2018)