Enlarge image
Qualified 2017 Disaster Retirement OMB No. 1545-0074
Form 8915-B
Plan Distributions and Repayments
▶ Go to www.irs.gov/Form8915B for instructions and the latest information. 2021
Department of the Treasury ▶ For coronavirus-related distributions, see Form 8915-F. Attachment
Internal Revenue Service ▶ Attach to 2021 Form 1040, 1040-SR, or 1040-NR. Sequence No. 915
Name. If married, file a separate form for each spouse required to file 2021 Form 8915-B. 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
if You Are Filing This below. See instructions. If this is an
Form by Itself and Not amended return,
With Your Tax Return check here ▶
Foreign country name Foreign province/state/county Foreign postal code
Part I Qualified 2017 Disaster Distributions From Retirement Plans (Other Than IRAs)
1a Enter the amount, if any, from your 2020 Form 8915-B, line 6 . . . . . . 1a
1b Enter the amount, if any, from your 2020 Form 8915-B, line 1 . . . . . . 1b
2a Subtract line 1b from line 1a. If zero or less, enter -0-. This is your excess
repayment from 2020 . . . . . . . . . . . . . . . . . . . 2a
2b 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 2021 that were not included on your 2020
Form 8915-B. But don’t include repayments made after the 3-year cutoff date. Don’t use this form to
report repayments of qualified 2018, 2019, or 2020 disaster distributions. 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 2017 Disaster Distributions From Traditional, SEP, SIMPLE, and Roth IRAs
6a Enter the amount, if any, from your 2020 Form 8915-B, line 13 . . . . . 6a
6b Enter the amount, if any, from your 2020 Form 8915-B, line 8 . . . . . . 6b
7a Subtract line 6b from line 6a. If zero or less, enter -0-. This is your excess
repayment from 2020 . . . . . . . . . . . . . . . . . . . 7a
7b 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 2021 that were not included on your 2020
Form 8915-B. But don’t include repayments made after the 3-year cutoff date. Don’t use this form to
report repayments of qualified 2018, 2019, or 2020 disaster distributions. 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 your tax return instructions. Cat. No. 71180D Form 8915-B (2021)