Qualified 2019 Disaster Retirement                                                                 OMB No. 1545-0074
Form 8915-D
                                              Plan Distributions and Repayments
                                                   Attach to 2024 Form 1040, 1040-SR, or 1040-NR.                                                 2024
Department of the Treasury        Go to www.irs.gov/Form8915D 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 2024 Form 8915-D. See instructions.                 Your social security number

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Only if You Are Filing      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 
This Form by Itself                                                                                                                              return, check here
and Not With Your 
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Part I     Qualified Disaster Distributions for the Puerto Rico Earthquakes (DR-4473-PR) Disaster From 
           Retirement Plans (Other Than IRAs)
1a   Enter the amount, if any, from your 2023 Form 8915-D, line 6  .          . . . . .                     .   1a
b    Enter the amount, if any, from your 2023 Form 8915-D, line 1  .          . . . . .                     .   1b
2 a  Subtract line 1b from line 1a. If zero or less, enter -0-. This is your excess repayment 
     from 2023  .        .  . . .         . . .  . . .   . . . . . .          . . . . .                     .   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 for 2024. See instructions. Don’t use this form to report 
     repayments  of  qualified  disaster  distributions  for  disasters  other  than  the  Puerto  Rico  Earthquakes 
     (DR-4473-PR) disaster .              . . .  . . .   . . . . . .          . . . . .                     . . .   . . . .     . .            4
5    Add lines 3 and 4. This amount can be carried back to a prior year to reduce the amount subject to tax in 
     that year. See instructions  .         . .  . . .   . . . . . .          . . . . .                     . . .   . . . .     . .            5
Part II    Qualified Disaster Distributions for the Puerto Rico Earthquakes (DR-4473-PR) Disaster From 
           Traditional, SEP, SIMPLE, and Roth IRAs
6a   Enter the amount, if any, from your 2023 Form 8915-D, line 13            . . . . .                     .   6a
b    Enter the amount, if any, from your 2023 Form 8915-D, line 8  .          . . . . .                     .   6b
7 a  Subtract line 6b from line 6a. If zero or less, enter -0-. This is your excess repayment 
     from 2023  .        .  . . .         . . .  . . .   . . . . . .          . . . . .                     .   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 for 2024. See instructions. Don’t use this form to report 
     repayments  of  qualified  disaster  distributions  for  disasters  other  than  the  Puerto  Rico  Earthquakes 
     (DR-4473-PR) disaster  .             . . .  . . .   . . . . . .          . . . . .                     . . .   . . . .     . .            9
10   Add lines 8 and 9. This amount can be carried back to a prior year to reduce the amount subject to tax in 
     that year. See instructions  .         . .  . . .   . . . . . .          . . . . .                     . . .   . . . .     . .            10
                              Under  penalties  of  perjury,  I  declare  that  I  have  examined  this  form,  including  accompanying  attachments,  and  to  the  best  of  my 
Sign Here Only if You         knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which 
Are Filing This Form          preparer has any knowledge.
by Itself and Not With 
Your Tax Return               Your signature                                                                              Date
           Print/Type preparer’s name                    Preparer’s signature                                   Date
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                                                                                                                                self-employed 
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For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.                                  Cat. No. 73793G                  Form 8915-D (2024)