Employee Retention Credit for Certain Tax-Exempt 
Form    5884-D
(April 2021)                             Organizations Affected by Qualified Disasters                                                     OMB No. 1545-2298
                                          ▶ 
Department of the Treasury                  File this form separately; do not attach it to your return.                                  
Internal Revenue Service          ▶ Go to www.irs.gov/Form5884D for instructions and the latest information.                  
Name (not trade name) shown on Form 941 or other employment tax return                                                  Employer identification number

Trade name (if any)

Number, street, and room or suite no. If a P.O. box, see instructions.

City or town, state, and ZIP code

1       If filed by a third-party payer, identify the qualified tax-exempt organization here. See instructions. Check      if not applicable.
        Name                                                                                                            Employer identification number

        Number, street, and room or suite no. If a P.O. box, see instructions.

        City or town, state, and ZIP code

2 a     Is  the  organization  a  qualified  tax-exempt  organization  (an  organization  described  in  section  501(c)  and 
        exempt from tax under section 501(a))? See instructions  .                 .   . . . . .    .    . . . . . .  . .                .    Yes   No
b       Is the organization a federally chartered corporation, or is it a federal, state, or local college, university, 
        hospital, or medical care entity? See instructions .               .  . .  .   . . . . .  .      . . . . . .  . .                .    Yes   No
        If you checked “Yes” on either line 2a or 2b, go to line 3. If you checked “No” on both lines 2a and 2b, do 
        not file this form; the organization cannot claim this credit. 
3       Applicable 2020 qualified disaster zone(s) (see instructions):

                           (a)                                                (b)                                       (c)  
                   Disaster declaration                                    Description                     County, parish, or municipality name(s)
                         number

             DR -                -

             DR -                -

             DR -                -

             DR -                -

4       Check a box to indicate the employment tax return filed:
        a    Form 941      b      Form 941-PR   c Form 941-SS                      d     Form 943 e        Form 943-PR
        f    Form 944 (or 944(SP))              g Form 944-PR                      h     Form 944-SS
5       Check a box or boxes to indicate the employment tax period for which the organization is claiming this credit. See instructions:
a       Check year:        2019           2020                        2021                   (enter year)
b       Check quarter (if applicable):
             1st: January, February, March        2nd: April, May, June
             3rd: July, August, September         4th: October, November, December

6 a     Enter  the  organization’s  total  qualified  wages  for  the  2020  qualified  disaster 
        employee retention credit paid in all employment tax periods through the end of 
        the  employment  tax  period  indicated  on  line  5  to  all  eligible  employees  (up  to 
        $6,000 each). See instructions   . .  . . .                   . .  .  . .  .   . . . . .         6a
b       Multiply line 6a by 40% (0.40)  .  .  . . .                   . .  .  . .  .   . . . . .  .      . . . . . .  .   6b
For Paperwork Reduction Act Notice, see instructions.                                    Cat. No. 75321C                                 Form 5884-D (4-2021) 

Form 5884-D (4-2021)                                                                                                                             Page  2 
7    Enter the number of eligible employees who earned the qualified wages for the 2020 qualified disaster 
     employee retention credit entered on line 6a  .  . . .      .   . . . . . .     .         .  . . . . .                        . 7
8    Enter the total amount of 2020 qualified disaster employee retention credits claimed on line 12 (minus
     any amounts reported on line 13) of any Forms 5884-D filed for prior employment tax periods by or on
     behalf of the organization. See instructions . . . . .      .   . . . . . .     .         .  . . . . .                        . 8
     Note: If line 8 is greater than line 6b, skip lines 9 through 12 and go to line 13. Otherwise, go to line 9.
9    Subtract line 8 from line 6b  .    . . . . .   . . . .      .   . . . . . .     .         .  . . . . .                        . 9
10   Enter the organization’s total taxable social security wages and tips reported on the return indicated
     on line 4 for the period indicated on line 5. See instructions  . . . . . .     .         .  . . . . .                        . 10
     Note: If a corrected return (for example, Form 941-X) was filed for the period indicated on line 5, enter 
     the amount as corrected.
11a  Multiply line 10 by 6.2% (0.062)     . . . .   . . . .      .   . . . . . .               11a
b    If Form 5884-C was filed for the period indicated on line 5 of this form, enter 
     the total amount of credits claimed on line 11 of Form 5884-C. See instructions           11b
c    Enter  the  total  amount  of  any  qualified  small  business  payroll  tax  credit  for 
     increasing research activities (Form 941, Form 943, or Form 944) filed for the
     period indicated on line 5 of this form. See instructions . .   . . . . . .               11c
d    Add lines 11b and 11c and subtract the total from line 11a. If the result is less 
     than zero, enter -0-       . .   . . . . . .   . . . .      .   . . . . . .               11d
12   Credit claimed for the employment tax period indicated on line 5. Enter the smaller of line 9 or line 
     11d. This is the amount you are asking us to refund to you. Stop here, sign, and mail this form to the 
     address below. See instructions      . . . .   . . . .      .   . . . . . .     .         .  . . . . .                        . 12
13   If line 8 is greater than line 6b, subtract line 6b from line 8. This is the amount you owe. Sign and mail 
     this form to the address below with your payment for this amount. See instructions           . . . . .                        . 13
Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and 
belief, it is true, correct, and complete. Declaration of preparer is based on all information of which preparer has any knowledge.
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Here
           Signature of officer                           Title                                           Date
           Print/Type preparer’s name           Preparer’s signature                           Date                                    PTIN
Paid                                                                                                      Check         if 
                                                                                                          self-employed
Preparer 
Use Only   Firm’s name      ▶                                                                         Firm’s EIN  ▶
           Firm’s address  ▶                                                                          Phone no.
                     Send Form 5884-D to: Department of the Treasury, Internal Revenue Service, Ogden, UT 84201
                                                                                                                                      Form 5884-D (4-2021)