8915-D Qualified 2019 Disaster Retirement Plan Distributions an

Form

8915-D

Qualified 2019 Disaster Retirement
Plan Distributions and Repayments

OMB No. 1545-0074

2024

Attach to 2024 Form 1040, 1040-SR, or 1040-NR.
Go to www.irs.gov/Form8915D for instructions and the latest information.
For coronavirus-related distributions, see Form 8915-F.

Department of the Treasury
Internal Revenue Service

Attachment
Sequence No. 915
Your social security number

Name. If married, file a separate form for each spouse required to file 2024 Form 8915-D. See instructions.
Home address (number and street, or P.O. box if mail is not delivered to your home)

Apt. no.

Fill in Your Address
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
If this is an amended
instructions.
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 Disaster Distributions for the Puerto Rico Earthquakes (DR-4473-PR) Disaster From
Retirement Plans (Other Than IRAs)

1a
b

Enter the amount, if any, from your 2023 Form 8915-D, line 6 .
Enter the amount, if any, from your 2023 Form 8915-D, line 1 .

2a

Subtract line 1b from line 1a. If zero or less, enter -0-. This is your excess repayment
from 2023 . . . . . . . . . . . . . . . . . . . . . . .

b
3

.
.

.
.

.
.

.
.

.
.

Enter the amount from line 2a that you have already carried back to a prior year .
Subtract line 2b from line 2a . . . . . . . . . . . . . . . .

.
.

.
.

1a
1b
2a
2b
. . .

.

.

.

.

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
b

Enter the amount, if any, from your 2023 Form 8915-D, line 13
Enter the amount, if any, from your 2023 Form 8915-D, line 8 .

7a

Subtract line 6b from line 6a. If zero or less, enter -0-. This is your excess repayment
from 2023 . . . . . . . . . . . . . . . . . . . . . . .

b
8

.
.

.
.

.
.

.
.

.
.

Enter the amount from line 7a that you have already carried back to a prior year
Subtract line 7b from line 7a . . . . . . . . . . . . . . . .

.
.

.
.

6a
6b
7a
7b
. . .

.

.

.

.

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

Sign Here Only if You
Are Filing This Form
by Itself and Not With
Your Tax Return

Paid
Preparer
Use Only

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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.

Your signature

Print/Type preparer’s name

Date
Preparer’s signature

Date

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Firm’s EIN

Firm’s address

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Check
if PTIN
self-employed

Phone no.
Cat. No. 73793G

Form 8915-D (2024)