2006 Form 8915 Qualified Hurricane Retirement Plan Distributions and Repayments modified to report recovery assistance distributions and repayments (page 1). Summary: This is a sample of page 1 of the 2006 Form 8915, it has been modified to report qualified recovery assistance distributions and repayments and it illustrates Example 2. 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. Enter in columns (b) and (c) the amount, if any, from your 2007 Form 8915, line 4 column (b). If this amount is $100,000 or more, do not complete this part, you have no qualified recovery assistance distributions for 2008” column (b) field contains 45,000; column (c) field contains 45,000

“2. Distributions from retirement plans” column (a) field contains 15,000; column (b) field contains 15,000

“5. Totals. Add lines 1 through 4 in columns (a) and (b). Complete column (c) only if line 5, column (b), is more than $100,000” column (a) field contains 15,000, column (b) field contains 60,000, column (c) field contains 100,000

“6. Subtract line 1 (in columns (b) and (c)) from $100,000” column (b) field contains 55,000, column (c) field contains 45,000

“7. If you completed column (c), enter the excess of the amount on line 5, column (a), over the amount on line 6, column (c). Otherwise, enter the excess of the amount on line 5, column (a), over the sum of the amounts on lines 2 through 4 in column (b). Report these distributions under the normal rules in accordance with the instructions for your tax return” field contains -0-

“8. Did you enter an amount on line 2, column (b) ? No. Skip lines 8 through 11, and go to line 12. Yes. If you completed line 2, column (c), enter that amount. Otherwise, enter the amount from line 2, column (b).” The yes checkbox is checked and the field contains 15,000

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

“10. Subtract line 9 from line 8” field contains 15,000

“11. If you elect NOT to spread the taxable amount over 3 years, check this box and enter the amount from line 10. You must check this box if you check the box on line 26. Otherwise, divide line 10 by 3.0” field contains 5,000

“12. Enter the amount, if any, from your 2007 Form 8915, line 9. If you checked the box on that line enter -0-” field contains 10,000

“13. Add lines 11 and 12” field contains 15,000

“14. Enter the amount, if any, from your 2007 Form 8915, line 10” field contains -0-

“15. Enter the amount, if any, from your 2007 Form 8915, line 9” field contains 10,000

“16. Subtract line 15 from line 14. If zero or less enter -0-” field contains -0-

“17. Enter the total amount of any repayments you made before filing your 2008 tax return. But do not include repayments made later than the due date (including extensions) for that return. See instructions.” field contains -0-

“18. Add line 16 and 17” field contains -0-

“19. Amount subject to tax in 2008. Subtract line 18 from line 13. 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 15,000