OMB No. 1545-0074
                                              Qualified 2019 Disaster Retirement 
Form 8915-D
                                              Plan Distributions and Repayments
                                                   Attach to 2023 Form 1040, 1040-SR, or 1040-NR.                                                 2023
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 2023 Form 8915-D. 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.
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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 
Tax Return                  Foreign country name               Foreign province/state/county                                Foreign postal code

Part I     Qualified 2019 Disaster Distributions From Retirement Plans (Other Than IRAs)
1    Enter the amount, if any, from your 2021 Form 8915-D, line 11. If you checked the box on that line, enter -0-                             1
2a   Enter the amount, if any, from your 2022 Form 8915-D, line 8  .        . . . . .                       .   2a
b    Enter the amount, if any, from your 2022 Form 8915-D, line 3  .        . . . . .                       .   2b
3a   Subtract  line  2b  from  line  2a.  If  zero  or  less,  enter  -0-.  This  is  your  excess 
     repayment from 2022  .               . . .  . . . . . . . . .          . . . . .                       .   3a
b    Enter the amount from line 3a that you have already carried back to a prior year .                     .   3b
4    Subtract line 3b from line 3a  .         .  . . . . . . . . .          . . . . .                       . . .   . . . .     . .            4
5    Enter the total amount of any repayments you made for 2023. See instructions. Don’t use this form to report 
     repayments of qualified disaster distributions for disasters other than qualified 2019 disasters                   . .     . .            5
6    Add lines 4 and 5      . .           . . .  . . . . . . . . .          . . . . .                       . . .   . . . .     . .            6
7    Amount subject to tax in 2023. Subtract line 6 from line 1. If zero or less, enter -0-. Include this amount in 
     the total on 2023 Form 1040, 1040-SR, or 1040-NR, line 5b  .           . . . . .                       . . .   . . . .     . .            7
Part II    Qualified 2019 Disaster Distributions From Traditional, SEP, SIMPLE, and Roth IRAs
8    Enter the amount, if any, from your 2021 Form 8915-D, line 27. If you checked the box on that line, enter -0-                             8
9a   Enter the amount, if any, from your 2022 Form 8915-D, line 17          . . . . .                       .   9a
b    Enter the amount, if any, from your 2022 Form 8915-D, line 12          . . . . .                       .   9b
10a  Subtract  line  9b  from  line  9a.  If  zero  or  less,  enter  -0-.  This  is  your  excess 
     repayment from 2022  .               . . .  . . . . . . . . .          . . . . .                       .   10a
b    Enter the amount from line 10a that you have already carried back to a prior year  .                       10b
11   Subtract line 10b from line 10a   .         . . . . . . . . .          . . . . .                       . . .   . . . .     . .            11
12   Enter the total amount of any repayments you made for 2023. See instructions. Don’t use this form to report 
     repayments of qualified disaster distributions for disasters other than qualified 2019 disasters                   . .     . .            12
13   Add lines 11 and 12 .    .           . . .  . . . . . . . . .          . . . . .                       . . .   . . . .     . .            13
14   Amount subject to tax in 2023. Subtract line 13 from line 8. If zero or less, enter -0-. Include this amount in 
     the total on 2023 Form 1040, 1040-SR, or 1040-NR, line 4b   .          . . . . .                       . . .   . . . .     . .            14
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 
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For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.                                  Cat. No. 73793G                  Form 8915-D (2023)