Form 8453-R - Electronic Filing Declaration for Form 8963

OMB 1545-2253

Use Form 8453-R to authenticate the electronic filing of Form 8963, Report of Health Insurance Provider Information.

The latest form for Form 8453-R - Electronic Filing Declaration for Form 8963 expires 2023-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 8453-R Form 8453-R - Electronic Filing Declaration for Form 8963 Form and Instruction
SUP STAT (Form 8453-R)_1545-2253_MS (N).docx Supporting Statement A
Form 8453-R - Electronic Filing Declaration for Form 8963 Form and Instruction

All Historical Document Collections

202002-1545-003 Approved without change	Extension without change of a currently approved collection	2020-06-29
201702-1545-012 Approved without change	Extension without change of a currently approved collection	2017-03-28
201401-1545-018 Approved without change	New collection (Request for a new OMB Control Number)	2014-01-29