Form 8915-C

2021

Qualified 2018 Disaster Retirement 

Plan Distributions and Repayments

Department of the Treasury 

Internal Revenue Service 

▶ Go to www.irs.gov/Form8915C for instructions and the latest information.

▶ For coronavirus-related distributions, see Form 8915-F.

▶ Attach to 2021 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 2021 Form 8915-C. 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 2018 Disaster Distributions From Retirement Plans (Other Than IRAs)

1 Enter the amount, if any, from your 2019 Form 8915-C, line 11. If you checked the box on that line, enter -0- 1

2 Enter the amount, if any, from your 2020 Form 8915-C, line 11. If you checked the box on that line, enter -0- 2

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

4a Enter the amount, if any, from your 2020 Form 8915-C, line 19 . . . . . . 4a

b Enter the amount, if any, from your 2020 Form 8915-C, line 14 . . . . . . 4b

5 a Subtract line 4b from line 4a. If zero or less, enter -0-. This is your excess repayment 

from 2020 . . . . . . . . . . . . . . . . . . . . . . . 5a

b Enter the amount from line 5a that you have already carried back to a prior year . 5b

6 Subtract line 5b from line 5a . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Enter the total amount of any repayments you made before filing your 2021 tax return. But don’t include 

repayments made later than the due date (including extensions) for that return or after the 3-year cutoff 

date. Don’t use this form to report repayments of qualified 2017, 2019, or 2020 disaster distributions. See 

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

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

9 Amount subject to tax in 2021. Subtract line 8 from line 3. If zero or less, enter -0-. Include this amount in 

the total on 2021 Form 1040, 1040-SR, or 1040-NR, line 5b . . . . . . . . . . . . . . . 9

Part II Qualified 2018 Disaster Distributions From Traditional, SEP, SIMPLE, and Roth IRAs

10 Enter the amount, if any, from your 2019 Form 8915-C, line 26. If you checked the box on that line, enter -0- 10

11 Enter the amount, if any, from your 2020 Form 8915-C, line 27. If you checked the box on that line, enter -0- 11

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

13a Enter the amount, if any, from your 2020 Form 8915-C, line 35 . . . . . . 13a

b Enter the amount, if any, from your 2020 Form 8915-C, line 30 . . . . . . 13b

14 a Subtract line 13b from line 13a. If zero or less, enter -0-. This is your excess 

repayment from 2020 . . . . . . . . . . . . . . . . . . . 14a

b Enter the amount from line 14a that you have already carried back to a prior year . 14b

15 Subtract line 14b from line 14a . . . . . . . . . . . . . . . . . . . . . . . . 15

16 Enter the total amount of any repayments you made before filing your 2021 tax return. But don’t include any 

repayments made later than the due date (including extensions) for that return or after the 3-year cutoff 

date. Don’t use this form to report repayments of qualified 2017, 2019, or 2020 disaster distributions. See 

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

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

18 Amount subject to tax in 2021. Subtract line 17 from line 12. If zero or less, enter -0-. Include this amount 

in the total on 2021 Form 1040, 1040-SR, or 1040-NR, line 4b . . . . . . . . . . . . . . 18

Part III Qualified Distributions for the Purchase or Construction of a Main Home in Qualified 2018 Disaster Areas

Caution: If you repaid, before June 18, 2020, a qualified distribution received in 2018 or 2019 for the purchase or construction of a main 

home in a qualified 2018 disaster area, report the repayment on an amended 2018 or 2019 Form 8915-C, Part IV, or an amended tax 

return, as applicable. See Part III under Specific Instructions in the instructions. If the qualified distribution was received in 2017, see 2017 

qualified distributions under Amending Form 8915-C in the instructions.

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 separate instructions. Cat. No. 72465B Form 8915-C (2021)