2005 Form 8915 Qualified Hurricane Retirement Plan Distributions and Repayments modified to report recovery assistance distributions and repayments (page 2). Summary: This is an example of page 2 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:

“12. Did you receive a qualified recovery assistance distribution from a traditional, SEP, SIMPLE or Roth IRA that is required to be reported on Form 8606? Yes. (checkbox) Go to line 13.” field contains check in yes checkbox

“13. Enter the amount, if any, from Form 8606,” field contains 13,125

“14. Enter the amount, if any, from Form 8606” field contains -0-

“15. If you completed line 2, column (c), enter that amount. Otherwise, enter the amount from line 2, column (b). Do not include any amounts reported on Form 8606” field contains -0-

“16. Add lines 13, 14, and 15” field contains 13,125

“17. If you elect NOT to spread the taxable amount over 3 years, check this box and enter the amount from line 16. You must check this box if you check the box on line 9. Otherwise, divide line 16 by 3.0” field contains 4,375

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

“19. Amount subject to tax in 2007. Subtract line 18 from line 17. If zero or less, enter -0-. Include this amount in the total on Form 1040, line 15b; Form 1040A, line 11b; or Form 1040NR, line 16b.” field contains 4.375