f8941_ss_2011_OMB2198

SUPPORTING STATEMENT
1. CIRCUMSTANCES NECESSITATING COLLECTION OF INFORMATION
Section 1421 of the Patient Protection and Affordable Care Act, PL 111-148, allows qualified small employers to
elect, beginning in 2010, a tax credit for 50% of their employee health care coverage expenses. Form 8941, Credit for
Small Employer Health Insurance Premiums, has been developed to help employers compute the tax credit.

2. USE OF DATA
Elgible small employers with less than 25 employees and average annual wages of less than $50,000 will qualify for
the credit. Form 8941 will help the taxpayer compute the tax credit and be in compliance with their tax filing
obligations. It also provides the Treasury Department and the IRS statistical data on how many taxpayers are
benfitting from the new law.

3. USE OF IMPROVED INFORMATION TECHNOLOGY TO REDUCE BURDEN
Upon approval, we plan to offer electronic filing on Form 8903. Form 8941 is an attachment to the business
tax return which could be filed with Form 1120, Form 1120-S, Form 1065 or other tax return.

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
The form is designed for a small business concern due to the statutory restrictions for eligibility. We have attempted to
minimize burden wherever possible.

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
Periodic meetings are held between IRS personnel and representatives of the American Bar Association, the National
Society of Public Accountants, the American Institute of Certified Public Accountants, and other professional groups to
discuss tax law and tax forms. During these meetings, there is an opportunity for those attending to make comments
regarding Form 8941.
In response to the Federal Register notice (75 FR 77046), dated December 10, 2010, we received no comments
during the comment period regarding Form 8941.

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
Not applicable.

12. ESTIMATED BURDEN OF INFORMATION COLLECTION
List the number of responses, time per response, and total burden for each form included in the submission.
The burden estimate is as follows:
Number of
Time per
Total
Responses
Response
Hours
Form 8941 & Worksheets

3,046,964

16 hrs., 59 min.

40,189,456

Estimates of the annualized cost to respondents for the hour burdens shown are not available at this time.

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

Page 5

Department of the Treasury–Internal Revenue Service

13. ESTIMATED TOTAL ANNUAL COST BURDEN TO RESPONDENTS
As suggested by OMB, our Federal Register notice dated December 10, 2010, 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. However, we did not
receive any responses from taxpayers on this subject. As a result, estimates of these cost burdens are not available at
this time.

14. ESTIMATED ANNUALIZED COST TO THE FEDERAL GOVERNMENT
After consultation with various functions within the Service, we have determined that the cost of developing,
printing, processing, distribution and overhead for the form is $15,000.

15. REASONS FOR CHANGE IN BURDEN
There were no changes made to the document that resulted in any change to the burden previously reported to OMB.
We are making this submission to renew the OMB approval.

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