Form 8915 - Qualified Hurricane Retirement Plan Distributions And Repayments - 2009

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8915
Qualified Hurricane Retirement
OMB No. 1545-0074
2009
Form
Plan Distributions and Repayments
Department of the Treasury
Attachment
Attach to Form 1040, Form 1040A, or Form 1040NR.
156
Internal Revenue Service
Sequence No.
Name. If married, file a separate form for each spouse required to file Form 8915. 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
If You are Filing This
City, town or post office, state, and ZIP code
Form by Itself and Not
With Your Tax Return
Part I
Qualified Hurricane Distributions From Retirement Plans (other than IRAs)
1
Enter the amount, if any, from your 2008 Form 8915, line 6
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1
2
Enter the amount, if any, from your 2008 Form 8915, 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 2009. But do not include repayments made
on or before the due date (including extensions) for filing your 2008 tax return. See
instructions .
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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 .
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5
Part II
Qualified Hurricane Distributions From Traditional, SEP, SIMPLE, and Roth IRAs
6
Enter the amount, if any, from your 2008 Form 8915, line 13 .
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6
7
7
Enter the amount, if any, from your 2008 Form 8915, 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 2009. But do not include repayments made
on or before the due date (including extensions) for filing your 2008 tax return. See
instructions .
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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 .
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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
Are Filing This Form
preparer has any knowledge.
by Itself and Not With
Your Tax Return
Your signature
Date
Preparer's SSN or PTIN
Date
Check if self-
Paid
Preparer’s
employed
signature
Preparer’s
Firm's name (or yours
Use Only
EIN
if self-employed),
address, and ZIP code
Phone no.
8915
Form
(2009)
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Cat. No. 37726T

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