Form 8453-R Declaration and Signature for Electronic Filing of Forms

Version A, Cycle 10

Form

8453-R

(January 2014)

Declaration and Signature for Electronic Filing of
Forms 8947 and 8963
▶ Information

about Form 8453-R and its instructions is at www.irs.gov/form8453r.

Department of the Treasury
Internal Revenue Service

For calendar year 20
Employer identification number

Name of organization

Part I

OMB No. 1545-XXXX

Type of Report
▲

Check the box for the type of report being filed with Form 8453-R.
Do not check more than one box in Part I.

Form 8947 check here.
Form 8963 check here.

Part II

Declaration of Officer

Under penalties of perjury, I declare that I have examined the electronic report, including accompanying statements, and, to the best of my knowledge and belief,
it is true, correct, and complete. If I am signing as the designated entity, I also declare that the above named entity is the common parent of an affiliated group or
other designated entity (as per the instructions). I understand that the designated entity will receive IRS communications relating to the fee imposed by ACA
section 9008 or 9010 and is to pay this fee to the IRS on behalf of the controlled group. Each entity that is a member of the controlled group is jointly and
severally liable for this fee. I further declare that each entity in the controlled group identified on the electronic report consents to the choice of the designated
entity indicated on that report. I further certify that I am an officer of the single-person covered entity or the designated entity, and that I am duly authorized to
sign this report on behalf of that covered entity. Each member of the controlled group that is a covered entity as of the end of the day on December 31, 2013, is
jointly and severally liable for any applicable penalty under ACA section 9010. (Where the designated entity is selected by the IRS, each entity in this report is
deemed to consent to the choice of designated entity.)
▲

Sign
Here

Internal Use Only
DRAFT AS OF
November 6, 2013

Signature of officer

Date

Print name of signing official

Title

Daytime telephone number
Fax number

Future Developments

For the latest information about developments related to Form
8453-R and its instructions, such as legislation enacted after they
were published, go to www.irs.gov/form8453r.

Purpose of Form
Use Form 8453-R to authenticate the electronic filing of:
• Form 8947, Report of Branded Prescription Drug Information, and
• Form 8963, Report of Health Insurance Provider Information.

Who Must File
If you are filing a Form 8947 or Form 8963 in 2014, you must upload
Form 8453-R with your electronically filed report.

When To File
Form 8453-R must be filed with your electronically filed Form 8947
or your Form 8963.

How To File
File Form 8453-R with the organization's electronically filed report.
Use a scanner to create a PDF file of the completed form and
upload it with your Form 8947 or your Form 8963.

Part II. Declaration of Officer
An electronically transmitted report will not be considered complete
(and therefore not considered filed) unless Form 8453-R is signed
For Paperwork Reduction Act Notice, see instructions.

by an officer of the organization, scanned into a PDF file, and
transmitted with the report.
The officer's signature allows the IRS to disclose to the
transmitter:
• An acknowledgement that the IRS has accepted the
organization's electronically filed report, and
• The reason(s) for a delay in processing the report.
The declaration of officer must be signed and dated by:
• The president, vice president, treasurer, assistant treasurer, chief
accounting officer, or
• Any other officer of the organization, such as an officer of the
single-person covered entity or the designated entity, authorized to
sign the organization's report.
Paperwork Reduction Act Notice. We ask for the information on this
form to carry out the Internal Revenue laws of the United States. You
are required to give us the information. We need it to ensure that you
are complying with these laws and to allow us to figure and collect the
right amount of fees.
You are not required to provide the information requested on a form
that is subject to the Paperwork Reduction Act unless the form displays
a valid OMB control number. Books or records relating to a form or its
instructions must be retained as long as their contents may become
material in the administration of any Internal Revenue law. The rules
governing the confidentiality of the Form 8947 and Form 8963 are
covered in Internal Revenue Code section 6104.
Cat. No. 60914Z

Form 8453-R (1-2014)