Form 8928 Return of Certain Excise Taxes Under chapter 43 of the I

Form

8928

(Rev. December 2013)
Department of the Treasury
Internal Revenue Service

Return of Certain Excise Taxes Under
Chapter 43 of the Internal Revenue Code
a Information

about Form 8928 and its separate instructions is at www.irs.gov/form8928.

Filer's tax year beginning
A

OMB No. 1545-2148

(Under sections 4980B, 4980D, 4980E, and 4980G)

and ending

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Name of filer (see instructions)

B Filer’s employer identification
number (EIN)

Number, street, and room or suite no. (if a P.O. box, see instructions)
City or town, state or province, country, and ZIP or foreign postal code

E Plan sponsor’s EIN

C

Name of plan

F Plan year ending (MM/DD/YYYY)

D

Name and address of plan sponsor

G Plan number

Part I

Tax on Failure To Satisfy Continuation Coverage Requirements Under Section 4980B
Complete a separate Part I, lines 1 through 6, for failures due to reasonable cause and not to willful neglect, and a
separate Part I, lines 12 through 14, for other failures, for each qualifying event for which one or more failures to
satisfy continuation coverage requirements that occurred during the reporting period (see instructions).

Section A – Failures Due to Reasonable Cause and Not to Willful Neglect

1
2
3
4

For
IRS
Use
Only

Enter the total number of days of noncompliance in the reporting period . . . . . . .
Enter the number of qualified beneficiaries for which a failure occurred
as a result of this qualifying event . . . . . . . . . . . .
2
If you entered 2 or more on line 2, multiply line 1 by $200. Otherwise, multiply line 1 by $100
If the failure was not discovered despite exercising reasonable diligence or was corrected
within the correction period and was due to reasonable cause, enter -0- here, and go to line 5.
Otherwise, enter the amount from line 3 on line 6 and go to line 7 . . . . . . . . .

5

If the failure was not corrected before the date a notice of examination of income tax liability
was sent to the employer and the failure continued during the examination period, multiply
$2,500 by the number of qualified beneficiaries for whom one or more failures occurred
(multiply by $15,000 to the extent the violations were more than de minimis for a qualified
beneficiary). If the failures were corrected before the date a notice of examination was sent,
enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6
7

Enter the smaller of line 3 or line 5 . . . . . . . . . . . . . . . . . . . .
If there was more than one qualifying event, add the amounts shown on line 6 of all forms, and
enter the total on a single “summary” form. Otherwise, enter the amount from line 6 above .

8

Enter the aggregate amount paid or incurred during the preceding tax
year for a single employer group health plan or the amount paid or
incurred during the current tax year for a multiemployer health plan to
provide medical care . . . . . . . . . . . . . . . .

9
10
11

1

3

4

5
6
7

8
Multiply line 8 by 10% (.10) . . . . . . . . . . . . . . . . . . . . . .
Amount from section 4980B(c)(4) . . . . . . . . . . . . . . . . . . . .
Enter the smallest of lines 7, 9, or 10. For a third-party administrator, HMO, or insurance
company, the amount you enter on this line filed for all plans you administer during the same
tax year cannot exceed $2 million; reduce the amount you would otherwise enter on this line to
the extent the amount for all plans would exceed this limit . . . . . . . . . . . .

9
10

500,000

11

Section B – Failures Due to Willful Neglect or Otherwise Not Due to Reasonable Cause
12
13
14
15

Enter the total number of days of noncompliance in the reporting period . . . . . . .
Enter the number of qualified beneficiaries for which a failure occurred
as a result of this qualifying event . . . . . . . . . . . .
13
If you entered 2 or more on line 13, multiply line 12 by $200. Otherwise, multiply line 12 by $100.
If there was more than one qualifying event, add the amounts shown on line 14 of all forms, and
enter the total on a single “summary” form. Otherwise, enter the amount from line 14 above . .

12

14
15

Section C – Total Tax Due Under Section 4980B
16

Add lines 11 and 15

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For Paperwork Reduction Act Notice, see instructions.

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Cat. No. 37742T

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126

16
Form 8928 (Rev. 12-2013)

Page 2

Form 8928 (Rev. 12-2013)

Name of filer:

Part II

Filer’s EIN:

Tax on Failure To Meet Portability, Access, Renewability, and Other Requirements Under Section 4980D
Complete a separate Part II, lines 17 through 23, for failures due to reasonable cause and not to willful neglect, and a separate Part II,
lines 29–32, for other failures to meet certain group health plan requirements that occurred during the reporting period (see instructions).

Section A – Failures Due to Reasonable Cause and Not to Willful Neglect

For
IRS
Use
Only

17
18
19
20
21

Enter the total number of days of noncompliance in the reporting period . . . .
Enter the number of individuals to whom the failure applies . . .
18
Multiply line 17 by line 18 . . . . . . . . . . . . . . .
19
Multiply line 19 by $100 . . . . . . . . . . . . . . . . . . . .
If the failure was not discovered despite exercising reasonable diligence or was
within the correction period and was due to reasonable cause, enter -0- here, and
22. Otherwise, enter the amount from line 20 on line 23 and go to line 24 . . . .

22

If the failure was not corrected before the date a notice of examination of income tax liability was
sent to the employer and the failure continued during the examination period, multiply $2,500 by the
number of qualified beneficiaries for whom one or more failures occurred (multiply by $15,000 to
the extent the violations were more than de minimis for a qualified beneficiary). If the failures were
corrected before the date a notice of examination was sent, enter -0- . . . . . . . . .

23
24

Enter the smaller of line 20 or line 22 . . . . . . . . . . . . . . . . . . .
If there was more than one failure, add the amounts shown on line 23 of all forms, and enter
the total on a single “summary” form. Otherwise, enter the amount from line 23 above . .

25

Enter the aggregate amount paid or incurred during the preceding tax year for
a single employer group health plan or the amount paid or incurred during the
current tax year for a multiemployer health plan to provide medical care . . .

26
27
28

Multiply line 25 by 10% (.10) . . . . .
Amount from section 4980D(c)(3) . . .
Enter the smallest of lines 24, 26, or 27 .

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25
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17

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corrected
go to line
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20

21

22
23
24

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26
27
28

500,000

Section B – Failures Due to Willful Neglect or Otherwise Not Due to Reasonable Cause
29
30
31
32
33

Enter the total number of days of noncompliance in the reporting period . . . . . . .
Enter the number of individuals to whom the failure applies . . .
30
Multiply line 29 by line 30 . . . . . . . . . . . . . . .
31
Multiply line 31 by $100 . . . . . . . . . . . . . . . . . . . . . . .
If there was more than one failure, add the amounts shown on line 32 of all forms, and enter
the total on a single “summary” form. Otherwise, enter the amount from line 32 above . .

29

32
33

Section C – Total Tax Due Under Section 4980D
34

Add lines 28 and 33

Part III
35
36

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Add lines 16, 34, 36, and 38 . . . . . . . . . . . . . . . . . . . . . .
Enter amount of tax paid with Form 7004 . . . . . . . . . . . . . . . . .
Tax due. Subtract line 40 from line 39. If less than zero, enter -0-, and go to line 42. If the result
is greater than zero, enter here and attach a check or money order payable to “United States Treasury.”
Write your name, identifying number, plan number, and “Form 8928” on your payment . . . . .

42

Overpayment. Subtract line 39 from line 40

128

35
36

137

37
38

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39
40

41
42

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Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer
has any knowledge.

Your signature

Print/Type preparer’s name

Preparer's signature

F

F

F

Paid
Preparer
Use Only

34

Tax Due or Overpayment

39
40
41

Sign
Here

127

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

Aggregate amount contributed to HSAs of employees within calendar year .
Total tax due under section 4980G. Multiply line 37 by 35% (.35) . . . . .

Part V

.

Tax on Failure To Make Comparable Archer MSA Contributions Under Section 4980E

Aggregate amount contributed to Archer MSAs of employees within calendar year .
Total tax due under section 4980E. Multiply line 35 by 35% (.35) . . . . . . .

Part IV
37
38

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Telephone number
Date

Check
if
self-employed

Firm’s name

a

Firm's EIN

Firm's address

a

Phone no.

Date
PTIN

a

Form 8928 (Rev. 12-2013)