Form 8930 - Qualified Disaster Recovery Assistance Retirement Plan Distributions And Repayments - 2012
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18930
Qualified Disaster Recovery Assistance
OMB No. 1545-0074
2012
Form
Retirement Plan Distributions and Repayments
Attachment
Department of the Treasury
Attach to Form 1040, Form 1040A, or Form 1040NR.
164
▶
Internal Revenue Service
Sequence No.
Your social security number
Name. If married, file a separate form for each spouse required to file Form 8930. 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 This
Form by Itself and Not
City, town or post office, state, and ZIP code
With Your Tax Return
Part I
Qualified Disaster Recovery Assistance Distributions From Retirement Plans (Other Than IRAs)
1
1
Enter the amount, if any, from your 2011 Form 8930, line 6
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2
Enter the amount, if any, from your 2011 Form 8930, line 1
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2
3
Subtract line 2 from line 1. If zero or less, enter -0- .
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3
4
Enter the total amount of any repayments you made in 2012. But do not include repayments
made on or before the due date (including extensions) for filing your 2011 tax return. See
instructions .
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4
Add lines 3 and 4. This amount can be carried back to reduce the amount subject to tax in a
5
prior year. See instructions .
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5
Part II
Qualified Disaster Recovery Assistance Distributions From Traditional, SEP, SIMPLE, and Roth IRAs
6
Enter the amount, if any, from your 2011 Form 8930, line 13 .
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6
7
7
Enter the amount, if any, from your 2011 Form 8930, line 8
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8
Subtract line 7 from line 6. If zero or less, enter -0- .
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8
9
Enter the total amount of any repayments you made in 2012. But do not include repayments
made on or before the due date (including extensions) for filing your 2011 tax return. See
instructions .
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9
Add lines 8 and 9. This amount can be carried back to reduce the amount subject to tax in a
10
prior year. See instructions .
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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
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
PTIN
Date
Paid
Check
if
self-employed
Preparer
Firm's name
Firm's EIN
▶
▶
Use Only
Firm's address
Phone no.
▶
8930
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Form
(2012)
Cat. No. 37744P
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