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

(November 2009)

Date

Filer tax year beginning
Name of filer (see instructions)

Signature

O.K. to print
Revised proofs
requested

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

Department of the Treasury
Internal Revenue Service

A

Action

OMB No. 1545-2148

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

,

and ending

,

B Filer’s employer identification
number (EIN)

Number, street, and room or suite no. (If a P.O. box, see instructions)
City or town, state, and ZIP code
C

Name of plan

D

Name and address of plan sponsor

Part I

E

Plan sponsor’s EIN

F

Plan year ending (MM/DD/YYYY)

G Plan number

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

Complete a separate Part I, lines 1 through 6 for unintentional failures, and a separate Part I, lines 12 through 14, for
other failures, for each qualifying event for which one or more failures to satisfy continuation coverage requirements
that occurred during the reporting period (see instructions).

Section A – Unintentional Failures
1
2
3
4

Enter the total number of days of noncompliance in the reporting period
Enter the number of qualified beneficiaries for which a failure occurred as a
2
result of this qualifying event
If you entered 2 or more on line 2, multiply line 1 by $200. Otherwise, multiply line 1 by $100
If the failure was not discovered despite exercising reasonable diligence or was corrected within
the correction period and was due to reasonable cause, enter -0- here, and then go to line 5.
Otherwise, enter the amount from line 3 on line 6 and go to line 7

5

If the failure was not corrected before the date a notice of examination of income tax liability was
sent to the employer and the failure continued during the examination period, multiply $2,500 by
the number of qualified beneficiaries for whom one or more failures occurred (multiply by $15,000
to the extent the violations were more than de minimis for a qualified beneficiary). If the failures
were corrected before the day a notice of examination was sent, enter -0-

6
7

Enter the smaller of line 3 or line 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
Enter the aggregate amount paid or incurred during the preceding tax year for
a single employer group health plan or the amount paid or incurred during the
8
current tax year for a multiemployer health plan to provide medical care

8

1

3

4

5
6
7

9
10

Multiply line 8 by 10% (.10)
Amount from section 4980B(c)(4)

9
10

11

Enter the smallest of lines 7, 9, or 10. For a third-party administrator, HMO, or insurance company,
the amount you enter on this line filed for all plans you administer during the same tax year cannot
exceed $2 million; reduce the amount you would otherwise enter on this line to the extent the
amount for all plans would exceed this limit

11

500,000

Section B – Other Failures
12
13
14
15

Enter the total number of days of noncompliance in the reporting period
Enter the number of qualified beneficiaries for which a failure occurred as
13
a result of this qualifying event
If you entered 2 or more on line 13, multiply line 12 by $200. Otherwise, multiply line 12 by $100
If there was more than one qualifying event, add the amounts shown on line 14 of all forms, and
enter the total on a single “summary” form. Otherwise, enter the amount from line 14 above

12

14
15

Section C – Total Tax Due Under Section 4980B
16

©

Add lines 11 and 15

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

Cat. No. 37742T

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Form

8928

(11-2009)

9
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 (11-2009)

Page

Name of filer:

Part II

2

Filer’s EIN:

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Tax on Failure To Meet Portability, Access, and Renewability Requirements Under Section 4980D
Complete a separate Part II, lines 17 through 23, for unintentional failures, and a separate Part II, lines 29-32, for other
failures to meet certain group health plan requirements that occurred during the reporting period (see instructions).

Section A – Unintentional Failures

17

17
18
19

Enter the total number of days of noncompliance in the reporting period
Enter the number of individuals to whom the failure applies
Multiply line 17 by line 18

20
21

Multiply line 19 by $100
If the failure was not discovered despite exercising reasonable diligence or was corrected within
the correction period and was due to reasonable cause, enter -0- here, and then go to line 22.
Otherwise, enter the amount from line 20 on line 23 and go to line 24

22

23
24
25

26
27
28

18
19

20

21

If the failure was not corrected before the date a notice of examination of income tax liability was
sent to the employer and the failure continued during the examination period, multiply $2,500 by
the number of qualified beneficiaries for whom one or more failures occurred (multiply by $15,000
to the extent the violations were more than de minimis for a qualified beneficiary). If the failures
were corrected before the day a notice of examination was sent, enter -0-

22
23

Enter the smaller of line 20 or line 22
If there was more than one failure, add the amounts shown on line 23 of all forms, and enter the
total on a single “summary” form. Otherwise, enter the amount from line 23 above
Enter the aggregate amount paid or incurred during the preceding tax year for
a single employer group health plan or the amount paid or incurred during the
current tax year for a multiemployer health plan to provide medical care
25

24

26
27
28

Multiply line 25 by 10% (.10)
Amount from section 4980D(c)(3)
Enter the smallest of lines 24, 26, or 27.

500,000

Section B – Other Failures
29

29
30
31

Enter the total number of days of noncompliance in the reporting period
Enter the number of individuals to whom the failure applies
Multiply line 29 by line 30

32
33

Multiply line 31 by $100
If there was more than one failure, add the amounts shown on line 32 of all forms, and enter the
total on a single “summary” form. Otherwise, enter the amount from line 32 above

30
31
32
33

Section C – Total Tax Due Under Section 4980D
34

Part III
35
36

35
36

©

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

Aggregate amount contributed to HSAs of employees within calendar year
Total tax due under section 4980G. Multiply line 37 by 35% (.35)

Part V

34

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

Aggregate amount contributed to Archer MSAs of employees within calendar year
Total tax due under section 4980E. Multiply line 35 by 35% (.35)

Part IV
37
38

©

Add lines 28 and 33

©

37
38

Tax Due or Overpayment

39
40

Add lines 16, 34, 36, and 38
Enter amount of tax paid with Form 7004

39
40

41

Tax due. Subtract line 40 from line 39. If less than zero, enter -0-, and go to line 42. 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
Overpayment. Subtract line 39 from line 40

41
42

42

Sign
Here
Paid
Preparer’s
Use Only

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.

©

©

Your signature

©

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

(11-2009)