Instructions For Form 8930 - Qualified Disaster Recovery Assistance Retirement Plan Distributions And Repayments - 2011 Page 3

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Do not include on line 12
amount of tax. You are required to give us
However, we may give this information to
!
repayments of qualified disaster
this information if you made certain
the Department of Justice for civil and
recovery assistance distributions
contributions or received certain
criminal litigation, and to cities, states, the
CAUTION
made after 2010 that were included on
distributions from qualified plans,
District of Columbia, and U.S.
your 2010 Form 8930.
including IRAs and other tax-favored
commonwealths and possessions to carry
accounts. Our legal right to ask for the
out their tax laws. We may also disclose
Example. You received a $90,000
information requested on this form is
this information to other countries under a
qualified disaster recovery assistance
sections 6001, 6011, 6012(a), and 6109
tax treaty, to federal and state agencies to
distribution on October 1, 2009, from your
and their regulations. If you do not
enforce federal nontax criminal laws, or to
Roth IRA because of the severe storms in
provide this information, or you provide
federal law enforcement and intelligence
the Midwestern disaster areas. On April 1,
incomplete or false information, you may
agencies to combat terrorism.
2012, you repay $30,000 to your Roth
be subject to penalties.
IRA. You file your return on April 10,
The average time and expenses
2012. Since the repayment was made
You are not required to provide the
required to complete and file this form will
before you filed your return, and not later
information requested on a form that is
vary depending on individual
than the due date (including extensions),
subject to the Paperwork Reduction Act
circumstances. For the estimated
you would enter the $30,000 repayment
unless the form displays a valid OMB
averages, see the instructions for your
on line 12.
control number. Books or records relating
income tax return.
to a form or its instructions must be
If you have suggestions for making this
Privacy Act and Paperwork Reduction
retained as long as their contents may
form simpler, we would be happy to hear
Act Notice. We ask for the information
become material in the administration of
from you. See the instructions for your
on this form to carry out the Internal
any Internal Revenue law. Generally, tax
income tax return.
Revenue laws of the United States. We
returns and return information are
need this information to ensure that you
confidential, as required by section 6103.
are complying with these laws and to
allow us to figure and collect the right
-3-
Instructions for Form 8930 (2011)

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