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

Version A, Cycle 2

Form

8453-R

(Rev. December 2016)

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

Department of the Treasury
Internal Revenue Service

For calendar year 20
Employer identification number

Name of organization

Part I

OMB No. 1545-2253

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

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.
Caution: Do not use Form 8453-R to file Form 8963 in 2017 because there is a moratorium on the health insurance providers fee
under ACA section 9010 for 2017. Please disregard references to Form 8963 and ACA section 9010 in this revision.

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 agent 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 person that is a controlled group member at the end of the day on
December 31, 2016, is jointly and severally liable for this fee. I further declare that each controlled group member 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 person who is a controlled group member at the end of the day on December
31, 2016, and would qualify as a covered entity in 2017 if it were a single-person covered entity 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.)
▲

INTERNAL USE ONLY
DRAFT AS OF
April 26, 2016

Sign
Here

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 2017, 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
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 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 this form are covered
in Internal Revenue Code section 6103.
The time needed to complete and file this form will vary
depending on individual circumstances. The estimated average time
is:
Recordkeeping .

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. 1 hr., 12 min.

Learning about the law or the form

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. 12 min.

Preparing and sending the form

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. 13 min.

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Comments. You can send us comments by going to
www.irs.gov/formspubs, clicking on "More Information," and then
clicking on "Give us feedback." You can also send your comments
to the Internal Revenue Service, Tax Forms and Publications
Division, 1111 Constitution Ave. NW, IR-6526, Washington, DC
20224. DO NOT SEND THE FORM TO THIS ADDRESS. Instead,
see How To File, earlier.

• The reason(s) for a delay in processing the report.
For Paperwork Reduction Act Notice, see instructions.

Cat. No. 60914Z

Form 8453-R (Rev. 12-2016)