Supporting_Statement_Form8453-R

SUPPORTING STATEMENT
1. CIRCUMSTANCES NECESSITATING COLLECTION OF INFORMATION
This is a new form established under Section 9010 of the Patient Protection and Affordable Care Act (PPACA), Public
Law No. 111-148 (124 Stat. 119 (2010)), as amended by section 10905 of PPACA, and as further amended by section
1406 of the Health Care and Education Reconciliation Act of 2010, Public Law 111-152 (124 Stat. 1029 (2010) , which
requires any covered entity engaged in the business of providing health insurance related to United States health risks
must annually report its net premiums. The purpose of the form is to authenticate the electronic filing of Form 8947,
Report of Branded Prescription Drug Information and Form 8963, Report of Health Insurance Provider Information.

2. USE OF DATA
The IRS will use Form 8453-R to authenticate the electronic filing of Forms 8947 and 8963.

3. USE OF IMPROVED INFORMATION TECHNOLOGY TO REDUCE BURDEN
We intend to offer electronic filing of Form 8453-R.

4. EFFORTS TO IDENTIFY DUPLICATION
We have attempted to eliminate duplication within the agency wherever possible.

5. METHODS TO MINIMIZE BURDEN ON SMALL BUSINESSES OR OTHER SMALL ENTITIES
We have attempted to minimize the burden on small businesses and other small entities.

6. CONSEQUENCES OF LESS FREQUENT COLLECTION ON FEDERAL PROGRAMS OR
POLICY ACTIVITIES
Not applicable.

Form 14029 (Rev. 4-2009) Catalog Number 51944B Page 4

Department of the Treasury–Internal Revenue Service

7. SPECIAL CIRCUMSTANCES REQUIRING DATA COLLECTION TO BE INCONSISTENT
WITH GUIDELINES IN 5 CFR 1320.5(d)(2)
Not applicable.

8. CONSULTATION WITH INDIVIDUALS OUTSIDE OF THE AGENCY ON AVAILABILITY
OF DATA, FREQUENCY OF COLLECTION, CLARITY OF INSTRUCTIONS AND FORMS,
AND DATA ELEMENTS
The IRS issued proposed regulations with respect to the fee on health insurance providers on March 1, 2013 [Federal
Register Notice, Reg-118315-12, 78 Fed Reg. 14034]. The public as an opportunity to make written or electronic
comments until June 3, 2013, with a follow-up public hearing scheduled for June 21, 2013. (Form 8963).
Final regulations were published November 19, 2013, at 78 FR 71476, as TD 9643.
The IRS and the Treasury Department issued temporary regulations describing the rules related to the annual fee
imposed on branded prescription drugs on August 15, 2011 [Federal Register Notice, 76 Fed. Reg. 51245, T.D. 9544].
The public had an opportunity to make written or electronic comments. The regulations provide each covered entity the
opportunity to provide information relevant to the determination of the fee by annually submitting Form 8947.
Form 8453-R is required to electronically verify receipt of both Form 8963 and Form 8947.
In response to the Federal Register notice (78 FR 69938), dated November 21, 2013, we received no comments
during the comment period regarding Form 8453-R.

9. EXPLANATION OF DECISION TO PROVIDE ANY PAYMENT OR GIFT TO RESPONDENTS
Not applicable.

10. ASSURANCE OF CONFIDENTIALITY OF RESPONSES
Generally, tax returns and tax return information are confidential as required by 26 USC 6103.

11. JUSTIFICATION OF SENSITIVE QUESTIONS
No personally identifiable information (PII) is collected.

12. ESTIMATED BURDEN OF INFORMATION COLLECTION
Estimated Number
of Responses

Form 8453-R ...................

Form 14029 (Rev. 4-2009) Catalog Number 51944B

2,550

Page 5

Estimated Time
per Response

1.62 hours

Total
Burden

4,131

Department of the Treasury–Internal Revenue Service

13. ESTIMATED TOTAL ANNUAL COST BURDEN TO RESPONDENTS
As suggested by OMB, our Federal Register notice dated November 21, 2013, requested public comments on
estimates of cost burden that are not captured in the estimates of burden hours, i.e., estimates of capital or start-up
costs and costs of operation, maintenance, and purchase of services to provide information. The additional taxpayer
cost burden would consist of out-of-pocket expenses incurred by taxpayer to prepare, submit, and maintain adequate
record. The largest component of any additional expense to taxpayers would be to maintain adequate records. We
estimate the average cost to be $50 per return.

14. ESTIMATED ANNUALIZED COST TO THE FEDERAL GOVERNMENT
The primary costs to the government consists of printing the form. The estimated cost of printing the form is $150.

15. REASONS FOR CHANGE IN BURDEN
This is a new form.

16. PLANS FOR TABULATION, STATISTICAL ANALYSIS AND PUBLICATION
Not applicable.

17. REASONS WHY DISPLAYING THE OMB EXPIRATION DATE IS INAPPROPRIATE
See attached.

18. EXCEPTIONS TO THE CERTIFICATION STATEMENT ON OMB PRA SUBMISSION FORM
Not Applicable.
Note: The following paragraph applies to all of the collections of information in this submission: An
agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the
collection of information displays a valid OMB control number. Books or records relating to a collection of information
must be retained as long as their contents may become material in the administration of any internal revenue law.
Generally, tax returns and tax return information are confidential, as required by 26 U.S.C. 6103.

19. REASON FOR EMERGENCY SUBMISSION

Form 14029 (Rev. 4-2009) Catalog Number 51944B

Page 6

Department of the Treasury–Internal Revenue Service

OMB EXPIRATION DATE

We believe the public interest will be better served by not printing an expiration
date on the form(s) in this package.
Printing the expiration date on the form will result in increased costs because of the
need to replace inventories that become obsoleted by passage of the expiration date each
time OMB approval is renewed. Without printing the expiration date, supplies of the form
could continue to be used.
The time period during which the current edition of the form(s) in this package will
continue to be usable cannot be predicted. It could easily span several cycles of review and
OMB clearance renewal. In addition, usage fluctuates unpredictably. This makes it
necessary to maintain a substantial inventory of forms in the supply line at all times. This
includes supplies owned by both the Government and the public. Reprinting of the form
cannot be reliably scheduled to coincide with an OMB approval expiration date. This
form may be privately printed by users at their own expense. Some businesses print
complex and expensive marginally punched continuous versions, at their expense, for use
in their computers. The form may be printed by commercial printers and stocked for sale.
In such cases, printing the expiration date on the form could result in extra costs to the
users.
Not printing the expiration date on the form(s) will also avoid confusion among
taxpayers who may have identical forms with different expiration dates in their possession.
For the above reasons we request authorization to omit printing the expiration date
on the form(s) in this package.