2005 Form 8915 Qualified Hurricane Retirement Plan Distributions and Repayments modified to report recovery assistance distributions and repayments. Summary: This is an example of the 2005 Form 8915 which has been modified to report qualified recovery assistance distributions and repayments. The modifications to the form are described in the text of the publication. Additionally, these line items are completed:

“Name. If married, file a separate form for each spouse required to file Form 8915. See instructions.” field contains Margaret Maple

“Your social security number” field contains 789-00-1234

“Home address (number and street, or P.O. box if mail is not delivered to your home)” field contains 239 S. Main Street

“City, town, or post office, state, and ZIP code” field contains Greensburg, KS 67054

“1. Distributions from retirement plans, column (b) Qualified distributions (see instructions)” field contains 30,000

“2. Distributions from traditional, SEP, and SIMPLE IRAs, column (a) Total distributions for 2007” field contains 30,000

“2. Distributions from traditional, SEP, and SIMPLE IRAs, column (b) Qualified distributions (see instructions)” field contains 15,000

“Totals. Add lines 1 through 3 in columns (a) and (b). Complete column (c) only if line 4, column (b), is more than $100,000, column (a) Total distributions for 2007” field contains 60,000

“Totals. Add lines 1 through 3 in columns (a) and (b). Complete column (c) only if line 4, column (b), is more than $100,000, column (b) Qualified distributions (see instructions)” field contains 45,000

“Totals. Add lines 1 through 3 in columns (a) and (b). Complete column (c) only if line 4, column (b), is more than $100,000, column (c) Allocation of column (b) (see instructions)” field contains 100,000

“5. If you completed column (c), enter the excess of the amount on line 4, column (a), over $100,000. Otherwise, enter the excess of the amount on line 4, column (b). Report these distributions under the normal rules in accordance with the instructions for your tax return, or if applicable, on line 21 of this form.” field contains 15,000

“6. If you completed line 1, column (c), enter that amount. Otherwise, enter the amount from line 1, column (b)” field contains $30,000

“7. Enter the applicable cost of distributions, if any. See instructions”field contains -0-

“8. Subtract line 7 from line 6” field contains 30,000

“9. If you elect NOT to spread the taxable amount over 3 years, check this box and enter the amount from line 8. You must check this box if you check the box on line 17. Otherwise, divide line 8 by 3.0” field contains 10,000

“10. Enter the total amount of any repayments you made before filing your 2007 tax return. But do not include repayments made later than the due date (including extensions) for that return. See instructions” field contains -0-

“11. Amount subject to tax in 2007. Subtract line 10 from line 9. If zero or less, enter -0-. Include this amount in the total on Form 1040, line 16b; Form 1040A, line 12b; or Form 1040NR, line 17b” field contains 10,000