- 1 -
|
Qualified 2018 Disaster Retirement OMB No. 1545-0074
Form 8915-C
Plan Distributions and Repayments
Attach to 2023 Form 1040, 1040-SR, or 1040-NR. 2023
Department of the Treasury Go to www.irs.gov/Form8915C for instructions and the latest information. Attachment
Internal Revenue Service For coronavirus-related distributions, see Form 8915-F. Sequence No. 915
Name. If married, file a separate form for each spouse required to file 2023 Form 8915-C. See instructions. Your social security number
Home address (number and street, or P.O. box if mail is not delivered to your home) Apt. no.
Fill in Your Address Only City, town or post office, state, and ZIP code. If you have a foreign address, also complete the spaces below.
if You Are Filing This See instructions. If this is an amended
return, check here .
Form by Itself and Not
With Your Tax Return
Foreign country name Foreign province/state/county Foreign postal code
Part I Qualified 2018 Disaster Distributions From Retirement Plans (Other Than IRAs)
1a Enter the amount, if any, from your 2022 Form 8915-C, line 6 . . . . . . . 1a
b Enter the amount, if any, from your 2022 Form 8915-C, line 1 . . . . . . . 1b
2 a Subtract line 1b from line 1a. If zero or less, enter -0-. This is your excess repayment
from 2022 . . . . . . . . . . . . . . . . . . . . . . . 2a
b Enter the amount from line 2a that you have already carried back to a prior year . 2b
3 Subtract line 2b from line 2a . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Enter the total amount of any repayments you made in 2023 that were not included on your 2022 Form
8915-C. But don’t include repayments made after the 3-year cutoff date. Don’t use this form to report
repayments of qualified disaster distributions for disasters other than qualified 2018 disasters. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Add lines 3 and 4. This amount can be carried back to reduce the amount subject to tax in a prior year. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Part II Qualified 2018 Disaster Distributions From Traditional, SEP, SIMPLE, and Roth IRAs
6a Enter the amount, if any, from your 2022 Form 8915-C, line 13 . . . . . . 6a
b Enter the amount, if any, from your 2022 Form 8915-C, line 8 . . . . . . . 6b
7 a Subtract line 6b from line 6a. If zero or less, enter -0-. This is your excess
repayment from 2022 . . . . . . . . . . . . . . . . . . . 7a
b Enter the amount from line 7a that you have already carried back to a prior year . 7b
8 Subtract line 7b from line 7a . . . . . . . . . . . . . . . . . . . . . . . . . 8
9 Enter the total amount of any repayments you made in 2023 that were not included on your 2022 Form
8915-C. But don’t include any repayments made after the 3-year cutoff date. Don’t use this form to report
repayments of qualified disaster distributions for disasters other than qualified 2018 disasters. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
10 Add lines 8 and 9. This amount can be carried back to reduce the amount subject to tax in a prior year. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Sign Here Only if You 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.
Are Filing This Form
by Itself and Not With
Your Tax Return Your signature Date
Print/Type preparer’s name Preparer’s signature Date
Paid Check if PTIN
self-employed
Preparer
Firm’s name Firm’s EIN
Use Only Firm’s address Phone no.
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 72465B Form 8915-C (2023)
|