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

Instructions for Form 8928

Department of the Treasury
Internal Revenue Service

(September 2011)

Return of Certain Excise Taxes Under Chapter 43
of the Internal Revenue Code
Section references are to the Internal
Revenue Code unless otherwise noted.

General Instructions
Purpose of Form
File Form 8928 to report the tax due on
the following failures by group health
plans or employers.
• A failure to provide a level of
coverage of the costs of pediatric
vaccines (as defined in section 2612 of
the Public Health Services Act) that is
not below the coverage provided as of
May 1, 1993.
• A failure to satisfy continuation
coverage requirements under section
4980B.
• A failure to meet portability, access,
renewability, and market reform
requirements under sections 9801,
9802, 9803, 9811, 9812, 9813, and
9815.
• A failure to make comparable Archer
MSA contributions under section
4980E.
• A failure to make comparable health
savings account (HSA) contributions
under section 4980G.

Who Must File
Form 8928 must be filed by:
1. Any employer, group health plan,
plan administrator, or plan sponsor
liable for the tax under section 4980B
for failure to provide the required level
of pediatric vaccine coverage or to offer
continuation coverage to a qualified
beneficiary.
2. Any employer or group health
plan liable for the tax under section
4980D for failure to meet portability,
access, renewability, and market reform
requirements for group health plans
under sections 9801, 9802, 9803, 9811,
9812, 9813, and 9815.
3. Any employer liable for the tax
under section 4980E for failure to make
comparable Archer medical savings
account (MSA) contributions for all
participating employees.
4. Any employer liable for the tax
under section 4980G for failure to make
comparable health savings account
(HSA) contributions for all participating
employees.
Sep 16, 2011

When To File
For a failure under section 4980B or
section 4980D, if the failure is by an
employer or other person responsible
for providing or administering benefits
under the plan (such as an insurer or
third-party administrator), file Form
8928 on or before the due date for filing
the person’s federal income tax return.
If the failure under sections 4980B or
section 4980D is by a multiemployer or
multiple employer plan, file Form 8928
on or before the last day of the seventh
month following the end of the plan
year.
For a failure under section 4980E or
section 4980G, file Form 8928 on or
before the 15th day of the fourth month
following the calendar year in which the
noncomparable contributions were
made.
Extension. File Form 7004,
Application for Automatic Extension of
Time to File Certain Business Income
Tax, Information, and Other Returns, to
request an automatic extension of time
to file Form 8928. You must file Form
7004 on or before the regular due date
of Form 8928. See the instructions for
Form 7004 for more information. Form
7004 does not extend the time to pay
excise taxes due under Form 8928.

Where To File
File Form 8928 at the following
address.
Department of the Treasury
Internal Revenue Service
Cincinnati, OH 45999-0009
Private delivery services. You can
use certain private delivery services
designated by the IRS to meet the
“timely mailing as timely filing/paying”
rule for tax returns and payments.
These private delivery services include
only the following:
• DHL Express (DHL): DHL Same Day
Service.
• Federal Express (FedEx): FedEx
Priority Overnight, FedEx Standard
Overnight, FedEx 2Day, FedEx
International Priority, and FedEx
International First.
• United Parcel Service (UPS): UPS
Next Day Air, UPS Next Day Air Saver,
UPS 2nd Day Air, UPS 2nd Day Air
Cat. No. 52470C

A.M., UPS Worldwide Express Plus,
and UPS Worldwide Express.
The private delivery service can tell
you how to get written proof of the
mailing date.

Interest and Penalties
Interest. Interest is charged on taxes
not paid by the due date even if an
extension of time to file is granted.
Interest is also charged on penalties
imposed from the due date, including
extensions, to the date of payment for
failure to file, negligence, fraud, gross
valuation overstatements, and
substantial understatements of tax. The
interest rate is determined under
section 6621.
Penalty for late filing of return. If
you do not file a return by the due date,
including extensions, you may have to
pay a penalty of 5% of the unpaid tax
for each month or part of a month the
return is late, up to a maximum of 25%
of the unpaid tax. The minimum penalty
for a return that is more than 60 days
late is the smaller of the tax due or
$100. The penalty will not be imposed if
you can show that the failure to file on
time was due to reasonable cause. If
you file late, you must attach a
statement to Form 8928 explaining the
reasonable cause.
Penalty for late payment of tax. If
you do not pay the tax when due, you
may have to pay a penalty of 1/2 of 1%
of the unpaid tax for each month or part
of a month the tax is not paid, up to a
maximum of 25% of the unpaid tax.
The penalty will not be imposed if you
can show that the failure to pay on time
was due to reasonable cause.
Interest and penalties for late filing
and late payment will be billed
separately after the return is filed.

Claim for Refund or
Credit/Amended Return
File an amended Form 8928 for any of
the following:
• To claim a refund of overpaid taxes
reportable on Form 8928;
• To receive a credit for overpaid
taxes; or
• To report additional taxes due within
the same tax year of the filer if those
taxes have the same due date as those
previously reported.

File an amended return by writing
“Amended Return” at the top of Form
8928 and completing the appropriate
part.
If you file an amended return to
claim a refund or credit, the claim must
state in detail the reasons for claiming
the refund. In order for the IRS to
promptly consider your claim, you must
explain why you are filing the claim and
provide the appropriate supporting
evidence. See Regulations section
301.6402-2 for more details.

Specific Instructions
Filer tax year. Enter the tax year of
the employer, entity, or individual on
whom the tax is imposed by using the
plan year beginning and ending dates
entered in Part I of Form 5500 or by
using the tax year of the business
return filed, if applicable.
Item A. Name and address of filer.
Enter the name and address of the
employer, individual, or other entity who
is liable for the tax.
Include the suite, room, or other unit
numbers after the street number. If the
post office does not deliver mail to the
street address and you have a P.O.
box, show the box number instead of
the street address.
If the entity has a foreign address,
enter the information in the following
order: city or town, province or state,
and country. Follow the country’s
practice for entering the postal code.
Do not abbreviate the country name.
Item C. Name of plan. Enter the
formal name of the plan, name of the
plan sponsor, or name of the insurance
company or financial institution of the
direct filing entity (DFE). In the case of
a group insurance arrangement (GIA),
enter the name of the trust or other
entity that holds the insurance contract.
In the case of a master trust investment
account (MTIA), enter the name of the
sponsoring employers.
If the plan covers only the
employees of one employer, enter the
employer’s name or enough information
to identify the plan. This should be the
same name indicated on the Form
5500 series return/report if that form is
required to be filed for the plan.
Item D. Name and address of plan
sponsor. The term “plan sponsor”
means:
1. The employer, for a group health
plan established or maintained by a
single employer;
2. The employee organization, in
the case of a plan of an employee
organization;
3. The association, committee, joint
board of trustees, or other similar group

of representatives of the parties who
establish or maintain the plan, if the
group health plan is established or
maintained jointly by one or more
employers and one or more employee
organizations, or by two or more
employers.
Include the suite, room, or other unit
numbers after the street number. If the
post office does not deliver mail to the
street address and you have a P.O.
box, show the box number instead of
the street address.
If the plan sponsor has a foreign
address, enter the information in the
following order: city or town, province or
state, and country. Follow the country’s
practice for entering the postal code.
Do not abbreviate the country name.
Item E. Plan sponsor’s EIN. Enter
the nine-digit employer identification
number (EIN) assigned to the plan
sponsor. This should be the same
number used to file the Form 5500
series return/report.
Item F. Plan year ending. “Plan year”
is defined in Regulations section
54.9801-2. Enter eight digits in month/
date/year order. This number assists
the IRS in properly identifying the plan
and time period for which the Form
8928 is being filed. For example, a plan
year ended March 31, 2010, should be
shown as 03/31/2010.
Item G. Plan number. Enter the
three-digit number that the employer or
plan administrator assigned to the plan.
This three-digit number is used with the
EIN entered on line B and is used by
the IRS, the Department of Labor, and
the Pension Benefit Guaranty
Corporation as a unique 12-digit
number to identify the plan.
If the plan number is not
provided, this will cause a delay
CAUTION
in processing your return.
Filer’s signature. To reduce the
possibility of correspondence and
penalties, please sign and date the
form. Also enter a daytime phone
number where you can be reached.
Paid preparer’s signature. Anyone
who prepares your return and does not
charge you should not sign the return.
For example, a regular full-time
employee or your business partner who
prepares the return should not sign.
Generally, anyone who is paid to
prepare the return must sign the return
in the space provided and fill in the
Paid Preparer Use Only area. See
section 7701(a)(36)(B) for exceptions.
In addition to signing and completing
the required information, the paid
preparer must give a copy of the
completed return to the taxpayer.
Note. A paid preparer may sign
original or amended returns by rubber

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stamp, mechanical device, or computer
software program.

Part I. Tax on Failure To
Satisfy Continuation
Coverage Requirements
Under Section 4980B
Complete a separate Part I, Section A,
lines 1 through 6 for each qualifying
event for which one or more failures to
satisfy continuation coverage
requirements occurred during the
reporting period as a result of failures
due to reasonable cause and not to
willful neglect. If multiple qualifying
events occurred with different
noncompliance periods, complete lines
1 through 6 on a separate Part I for
each qualifying event. Then complete a
“summary” Form 8928 with items A
through G and enter the total amount of
the excise tax on line 7 of that summary
form and complete lines 8 through 11
for all qualifying events as a result of
failures due to reasonable cause and
not to willful neglect.
Complete a separate Part I, lines 12
through 14, for each qualifying event for
which one or more failures to satisfy
continuation coverage requirements
occurred during the reporting period as
a result of failures due to willful neglect
or otherwise not due to reasonable
cause. If multiple qualifying events
occurred with different noncompliance
periods, complete lines 12 through 14
on a separate Part I for each qualifying
event. Then complete a “summary”
Form 8928 with items A through G and
enter the total amount of the excise tax
on line 15 of that summary form for all
failures that were due to willful neglect
or otherwise not due to reasonable
cause.
Write “Summary Form” at the top to
indicate that this is a summary form
and attach all copies to it.
TIP

year.

You may report all failures on
the same form if the failures
occurred during the same tax

For purposes of Part I, a qualifying
event is any of the following.
• Death of the covered employee.
• Termination or reduction of hours of
the covered employee’s employment
(other than for employee gross
misconduct).
• Divorce or legal separation of the
covered employee from the employee’s
spouse.
• Covered employee becoming entitled
to Medicare benefits.
• Dependent child of the covered
employee ceasing to be a covered child
under the terms of the plan.

• Bankruptcy of the employer from
whose employment the covered
employee retired.

Waiver of excise tax. The Secretary
may waive part or all of the excise tax
under Part I, to the extent that payment
of the tax would be excessive relative
to the failure involved. This only applies
to failures due to reasonable cause and
not due to willful neglect.
Note. The tax under Part I will not
apply to the following.
• Any failure of a group health plan if
the qualifying event occurred during the
calendar year immediately following a
calendar year during which all
employers maintaining the plan
normally employed fewer than 20
employees on a typical business day.
• Any governmental plan under section
414(d).
• Any church plan under section
414(e).

Section A—Failures Due to
Reasonable Cause and Not
to Willful Neglect
If the failure or failures as a result of a
particular qualifying event were due to
reasonable cause and not to willful
neglect, complete Part I, Section A,
lines 1 through 11.
Line 1. Calculate the total number of
days of noncompliance within the
reporting period beginning on the date
the failure first occurred and ending on
the earlier of the date the failure is
corrected or, at the latest, a date that is
six months after the last day of the
maximum continuation coverage period
under the qualifying event that led to
the failure.
The noncompliance period may
include portions of more than
one plan year (in the case of an
employee benefit plan) or one tax year
(in the case of an employer or
third-party administrator). In that case,
only the portion of the noncompliance
period falling within that plan year or tax
year would be used to calculate the
excise tax due for that year.
TIP

Line 4. No tax is due for any failure
under Part I, Section A if it is
established to the satisfaction of the
Secretary of the Treasury that no one
liable for the tax knew, or exercising
reasonable diligence would have
known, that the failure occurred.
Additionally, no tax is due if the failure
under Part I, Section A was due to
reasonable cause and not due to willful
neglect and the failure was corrected
during the 30-day period beginning on
the 1st date anyone liable for the tax
knew, or exercising reasonable
diligence should have known, that the
failure existed.

For this purpose, a failure is treated
as corrected if the failure is retroactively
undone to the extent possible and the
qualified beneficiary to whom the failure
relates is placed in a financial position
which is as good as such beneficiary
would have been in had the failure not
occurred.
Line 5. The minimum excise tax under
Part I, Section A is $2,500 for each
qualified beneficiary for whom one or
more failures occurred if the failure or
failures were not corrected before the
date a notice of examination of income
tax liability was sent from the IRS and
the failure or failures continued during
the examination period. The minimum
excise tax under Part I, Section A is
$15,000 if the failure or failures are
determined to be more than de minimis.
Line 7. If you had more than one
qualifying event during the reporting
period, complete lines 1 through 6 in a
separate Part I, Section A for each
qualifying event and enter the total from
line 6 from all copies of Part I, Section
A on line 7 of your summary form. See
the discussion under Part I earlier.
Line 8. For a single employer plan,
enter on line 8 the aggregate amount
paid or incurred during the preceding
tax year by the employer (or a
predecessor) for its group health plan.
For a multiemployer plan, enter on this
line the amount paid or incurred during
the current tax year to provide medical
care, directly or through insurance or
reimbursement.
Line 11. The maximum excise tax
payable during a tax year by third-party
administrators, HMOs, and insurance
companies under Part I, Section A is
$2,000,000 for all plans for failures due
to reasonable cause not to willful
neglect. For those entities, do not enter
more than $2,000,000 on this line for
such failures for all plans even if the
aggregate excise tax owed for all
failures under Part I, Section A is more
than $2,000,000.

Section B—Failures Due to
Willful Neglect or Otherwise
Not Due to Reasonable
Cause
If the failure or failures as a result of a
particular qualifying event were due to
willful neglect or otherwise not due to
reasonable cause, complete Part I,
Section B, lines 12 through 15.
Line 12. Calculate the total number of
days of noncompliance within the
reporting period beginning on the date
the failure first occurred and ending on
the earlier of the date the failure is
corrected or, at the latest, a date that is
six months after the last day of the
maximum continuation coverage period

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under the qualifying event that led to
the failure.
Line 15. If you had more than one
qualifying event during the reporting
period, complete lines 12 through 14 in
a separate Part I, Section B for each
qualifying event and enter the total from
line 14 from all copies of Part I, Section
B on line 15 of your summary form. See
the discussion under Part I earlier.

Part II. Tax on Failure To
Meet Portability, Access,
and Renewability
Requirements Under
Section 4980D
Complete a separate Part II, Section A,
lines 17 through 23 for each failure to
meet portability, access, and
renewability requirements that occurred
during the reporting period that was
due to reasonable cause and not to
willful neglect. If multiple such failures
occurred with different noncompliance
periods, complete lines 17 through 23
in a separate Part I, Section A for each
failure. Then complete a “summary”
Form 8928 with items A through G and
enter the total amount of the excise tax
on line 24 of that summary form and
complete lines 25 through 28 for all
failures due to reasonable cause and
not to willful neglect.
Complete a separate Part II, Section
B, lines 29 through 33, for each failure
to meet portability, access, and
renewability requirements that occurred
during the reporting period that was
due to willful neglect or otherwise not
due to reasonable cause. If multiple
failures occurred with different
noncompliance periods, complete lines
29 through 32 on a separate Part II,
Section B for each failure. Then
complete a “summary” Form 8928 with
items A through G and enter the total
amount of the excise tax on line 33 of
that summary form for all such failures.
Write “Summary Form” at the top to
indicate that this is a summary form
and attach all copies to it.
Waiver of excise tax. The Secretary
may waive part or all of the excise tax
under Part II, to the extent that payment
of the tax would be excessive relative
to the failure involved. This only applies
to failures due to reasonable cause and
not due to willful neglect.
Exception for certain insured small
employer plans. If you are a small
employer who provides health
insurance coverage solely through a
contract with a health insurance issuer,
you will not be liable for the excise tax
under Part II for any failure (other than
a failure under section 9811) that is

solely the result of the health insurance
coverage offered by the issuer.
“Small employer” is generally
defined as an employer who employed
an average of at least 2 but not more
than 50 employees on business days
during the preceding calendar year, and
who employs at least 2 employees on
the first day of the current plan year.
Special rules apply to employers not in
existence in the preceding year. See
section 4980D(d)(2)(B).

Section A—Failures Due to
Reasonable Cause and Not
to Willful Neglect
If the failure or failures were due to
reasonable cause and not to willful
neglect, complete Part II, Section A,
lines 17 through 28.
Line 17. Calculate the total number of
days of noncompliance within the
reporting period beginning on the date
the failure first occurred and ending on
the date the failure is corrected.
The noncompliance period may
include portions of more than
one plan year (in the case of an
employee benefit plan) or one tax year
(in the case of an employer or
third-party administrator). In that case,
only the portion of the noncompliance
period falling within that plan year or tax
year would be used to calculate the
excise tax due for that year.
Line 21. No tax is due for any failure
under Part II, Section A if it is
established to the satisfaction of the
Secretary of the Treasury that no one
liable for the tax knew, or exercising
reasonable diligence would have
known, that the failure occurred.
Additionally, no tax is due if the failure
under Part II, Section A was due to
reasonable cause and not due to willful
neglect and the failure was corrected
during the 30-day period beginning on
the first date anyone liable for the tax
knew, or exercising reasonable
diligence would have known, that the
failure existed.
For this purpose, a failure is treated
as corrected if the failure is retroactively
undone to the extent possible and the
person to whom the failure relates is
placed in a financial position which is
as good as such person would have
been in had the failure not occurred.
In the case of a church plan, the
failure must be corrected before the
close of the correction period, as
defined under section 414(e)(4)(C).
Line 22. The minimum excise tax
under Part II, Section A is $2,500 for
each qualified beneficiary for whom one
or more failures occurred if the failure
or failures were not corrected before
the date a notice of examination of
TIP

income tax liability was sent from the
IRS and the failure or failures continued
during the examination period. The
minimum excise tax under Part II,
Section A, is $15,000 if the failure or
failures are determined to be more than
de minimis.
Exception for church plans. The
$2,500 (or $15,000 if applicable)
minimum excise tax does not apply to a
church plan, as defined in section
414(e). If your plan meets the
requirements for a church plan, enter
“-0-” on this line and go to line 23.
Line 24. If you had more than one
failure during the reporting period,
complete lines 17 through 23 in a
separate Part II, Section A for each
failure and enter the total from line 23
from all copies of Part II, Section A on
line 24 of your summary form. See the
discussion under Part I earlier.
Line 25. For a single employer plan,
enter on this line the aggregate amount
paid or incurred during the preceding
tax year by the employer (or a
predecessor) for its group health plan.
For a multiemployer plan, enter on this
line the amount paid or incurred during
the current tax year to provide medical
care, directly or through insurance or
reimbursement.

“Comparable contributions” are
contributions which are the same
amount or which are the same
percentage of the annual deductible
limit under the high deductible health
plan covering the employees.
“Comparable participating
employees” are employees who are
eligible individuals covered under any
high deductible health plan of the
employer, and who have the same
category of coverage.
To determine whether contributions
are comparable, see Regulations
sections 54.4980G-1 through
54.4980G-7.
Line 35. Enter the aggregate amount
contributed to employees’ Archer MSAs
for tax years ending with or within the
calendar year.
Waiver of excise tax. The Secretary
may waive part or all of the excise tax
under this part, to the extent that
payment of the tax would be excessive
relative to the failure involved. This only
applies to failures due to reasonable
cause and not to willful neglect.
Controlled group. For purposes of
this part, all persons treated as a single
employer under section 414(b), (c), (m),
or (o) will be treated as one employer.

Section B—Failure Due to
Willful Neglect or Otherwise
Not Due to Reasonable
Cause

Part IV. Tax on Failure
To Make Comparable
HSA Contributions
Under Section 4980G

If the failure or failures were due to
willful neglect or otherwise not due to
reasonable cause, complete Part II,
Section B, lines 29 through 33.
Line 29. Calculate the total number of
days of noncompliance within the
reporting period beginning on the date
the failure first occurred and ending on
the date the failure is corrected.
Line 33. If you had more than one
failure during the reporting period,
complete lines 29 through 32 in a
separate Part II, Section B for each
qualifying event and enter the total from
line 32 from all copies of Part II, Section
B on line 33 of your summary form. See
the discussion under Part I earlier.

An employer is liable for tax under
section 4980G if he fails to make
comparable contributions to the HSAs
of all comparable participating
employees for each coverage period
during the calendar year.
Line 37. Enter the aggregate amount
contributed to employees’ health
savings accounts for tax years ending
with or within the calendar year.
Waiver of excise tax. The Secretary
may waive part or all of the excise tax
under this part, to the extent that
payment of the tax would be excessive
relative to the failure involved. This only
applies to failures due to reasonable
cause and not to willful neglect.
Controlled group. For purposes of
this part, all persons treated as a single
employer under section 414(b), (c), (m),
or (o) will be treated as one employer.

Part III. Tax on Failure To
Make Comparable
Archer MSA
Contributions Under
Part V. Tax Due
Section 4980E
An employer is liable for tax under
section 4980E if he fails to make
comparable contributions to the Archer
MSAs of all comparable participating
employees for each coverage period
during the calendar year.

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Make your check or money
order payable to the “United
States Treasury” for the full
amount due. Attach the payment to
your return. Write your name,
identifying number, plan number, and

“Form 8928, Part(s)____” on your
payment.
File at the address shown under
Where To File, earlier.
Privacy Act and Paperwork
Reduction Act Notice. We ask for
the information on this form to carry out
the Internal Revenue laws of the United
States. Taxpayers subject to the
provisions of sections 4980B, 4980D,
4980E, and 4980G are required to
provide the information requested on
this form. Section 6109 requires you to
provide your identifying number. If you
fail to provide this information in a
timely manner, you may be liable for
penalties and interest. Routine uses of
this information include giving it to the
Department of Justice for civil and
criminal litigation, to other federal
agencies as authorized by law, and to
cities, states, the District of Columbia,
and U.S. commonwealths and
possessions for use in administering

their tax laws. We may also disclose
this information to other countries under
a tax treaty, to federal and state
agencies to enforce federal nontax
criminal laws, or to federal law
enforcement and intelligence agencies
to combat terrorism.
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. Generally, tax returns and return
information are confidential, as required
by section 6103.
The time needed to complete and
file this form will vary depending on
individual circumstances. The
estimated average time is:

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Recordkeeping . . .

12 hrs., 40 min.

Learning about the
law or the form . . .

4 hrs., 0 min.

Preparing and
sending the form
to the IRS . . . . . . .

6 hrs., 47 min.

If you have comments concerning
the accuracy of these time estimates or
suggestions for making this form
simpler, we would be happy to hear
from you. You can write to the Internal
Revenue Service, Tax Products
Coordinating Committee,
SE:W:CAR:MP:T:T:SP, IR-6526, 1111
Constitution Ave. NW, Washington, DC
20224. Do not send this form to this
address. Instead, see Where To File on
page 1.