Form 8928 - Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code

Forms and Documents

Document Name	Status
Form 8928 Form 8928 - Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code Form	Modified
SSNFORMS_8928_REV.doc Supporting Statement A	2013-02-11

IC Document Collections

IC ID	Document Title	Status
189293	Form 8928 - Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code Form	Modified

ICR Details

OMB Control No: 1545-2148	ICR Reference No: 201301-1545-015
Status: Historical Active	Previous ICR Reference No: 200912-1545-021
Agency/Subagency: TREAS/IRS	Agency Tracking No: mb
Title: Form 8928 - Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/20/2013
	Date Received in OIRA: 02/11/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2016	36 Months From Approved	03/31/2013
Responses	100	0	100
Time Burden (Hours)	2,348	0	2,348
Cost Burden (Dollars)	0	0	0

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Abstract: Form 8928 is used by employers, group health plans, HMOs, and third party administrators to report and pay excise taxes due for failures under sections 4980B, 4980D, 4980E, and 4980G.

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Authorizing Statute(s): PL: Pub.L. 104 - 191 402(a). Name of Law: Health Insurance Portability and Accountability Act of 1996
   PL: Pub.L. 100 - 647 3011(d). Name of Law: Technical Corrections Act of 1988
   PL: Pub.L. 108 - 173 1201(d)(4)(A). Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003
   PL: Pub.L. 104 - 191 301(c)(4)(A). Name of Law: Health Insurance Portability and Accountability Act of 1996
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 50763	08/22/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 9452	02/08/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Form 8928 - Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code	8928	Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	100	100	0	0	0	0
Annual Time Burden (Hours)	2,348	2,348	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $25,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/11/2013

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