Form 8928 Return of Certain Excise Taxes Under Chapter 43 of the I

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Date

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 8928, PAGE 1 of 2
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
FLAT SIZE: 216 mm (81⁄ 2 ") x 279 mm (11")
PERFORATE: NONE

PRINTS: HEAD TO FOOT
INK: BLACK

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form

8928

(December 2008)

Filer tax year beginning
Name of filer (see instructions)

City or town, state, and ZIP code

Signature

O.K. to print
Revised proofs
requested

OMB No. 1545-XXXX

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(Under sections 4980B, 4980D, 4980E, and 4980G)

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and ending

B

,

Filer’s identifying number (see instructions)
Employer Identification number (EIN)
Social security number (SSN)

Number, street, and room or suite no. (If a P.O. box, see instructions)

E

Plan sponsor’s EIN

F

Plan year ending (MM/DD/YYYY)

G

Plan number

C

Name of plan

D

Name and address of plan sponsor

H

Are you claiming a limitation of penalty under Parts I or II due to unintentional failure? If so,check here

Part I

Date

Return of Certain Excise Taxes Under
Chapter 43 of the Internal Revenue Code

Department of the Treasury
Internal Revenue Service

A

Action

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.

Tax on Failure To Satisfy Continuation Coverage Requirements Under Section 4980B

Complete a separate Part I, lines 1 through 6, for each qualifying event for which one or more failures to satisfy
continuation coverage requirements that occured during the reporting period (see instructions)
1
2
3
4
5
6
7

Enter the total number of days of noncompliance in the reporting period
Enter the number of qualified beneficiaries for which a failure occured as result of this qualifying event
If enter entered 2 or more on line 2, multiply line 1 by $200. Otherwise, multiply line 1 by $100
If the failure was discovered after notice of examination sent, enter $2,500. Otherwise, enter -0To the extent the violations were more than de minimus, enter $15,000. Otherwise, enter -0Enter the largest of lines 3, 4, or 5
If there was more than one qualifying event, add the amounts shown on line 6 of all forms, and
enter the total on a single “summary” form. Otherwise, enter the amount from line 6 above. For a
third-party administrator, HMO, or insurance company, do not include more than $2,000,000 for
all unintentional failures (see instructions)

8
9
10
11

Enter the aggregate amount paid during the preceding tax year for group health plans
Multiply line 8 by 10% (.10)
Amount from section 4980B(c)(4)
Total tax due under section 4980B. If the failure was unintentional, enter the smallest of lines 7,
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9, or 10. Otherwise, enter the amount from line 7

Part II

1
2
3
4
5
6

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8
9
10

500,000

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Tax on Failure To Meet Portability, Access, and Renewability Requirements Under Section 4980D
Complete a separate Part II, lines 12 through 18, for each failure to meet certain group health plan requirements that
occured during the reporting period (see instructions)

12
13
14
15
16
17
18
19
20
21
22
23

Enter the total number of days of noncompliance in the reporting period
13
Number of individuals to whom the failure applies
14
Multiply line 12 by line 13
Multiply line 14 by $100
If the failure was discovered after notice of examination sent, enter $2,500. Otherwise, enter -0To the extent the violations were more than de minimus, enter $15,000. Otherwise, enter -0Enter the largest of lines 15, 16, or 17
If there was more than one failure, add the amounts shown on line 18 of all forms, and enter the
total on a single “summary” form. Otherwise, enter the amount from line 18 above
Enter the aggregate amount paid during the preceding tax year for group health plans
Multiply line 20 by 10% (.10)
Amount from section 4980D(c)(3)
Total tax due under section 4980D. If the failure was unintentional, enter the smallest of lines 19,
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21, or 22. Otherwise, enter the amount from line 19

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

Cat. No. 37742T

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15
16
17
18
19
20
21
22

500,000

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Form

8928

(12-2008)

2
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 8928, PAGE 2 of 2
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
FLAT SIZE: 216 mm (81⁄ 2 ") x 279 mm (11")
PERFORATE: NONE

PRINTS: HEAD TO FOOT
INK: BLACK

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 8928 (Rev. 12-2008)

Page

Name of filer:

Part III
24

25

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Tax on Failure To Make Comparable Archer MSA Contributions Under Section 4980E

Aggregate amount contributed to Archer MSAs of employees within
calendar year

24

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Total tax due under section 4980E. Multiply line 24 by 35% (.35)

Part IV

25

Tax on Failure To Make Comparable HSA Contributions Under Section 4980G

26

Aggregate amount contributed to HSAs of employees within calendar year

27

Total tax due under section 4980G. Multiply line 26 by 35% (.35)

Part V

Tax Due or Overpayment

26

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27

28

28

Add lines 11, 23, 25, and 27

29

Enter amount of tax paid with Form 7004

29

30

Tax due. Subtract line 29 from line 28. If less than zero, enter -0-, and go to line 31. If the result
is greater than zero, enter here and attach a check or money order payable to “United States
Treasury.” Write your name, identifying number, plan number, and “Form 8928” on your payment

30

Overpayment. Subtract line 28 from line 29

31

31

Sign
Here
Paid
Preparer’s
Use Only

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Filer’s identifying number:

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my
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.

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©

Your signature

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Preparer’s
signature
Firm’s name (or
yours, if self-employed),
address, and ZIP code

Date

©

©

Telephone number
Check
if selfemployed

Date

Preparer’s SSN or PTIN

EIN
Phone no. (

)
Form

8928

(12-2008)