i8928--2016-09-00

Instructions for Form 8928
(Rev. September 2016)

Department of the Treasury
Internal Revenue Service

For use with Form 8928 (Rev. May 2016)
Return of Certain Excise Taxes Under Chapter 43
of the Internal Revenue Code
Section references are to the Internal Revenue
Code unless otherwise noted.

Future Developments

For the latest information about Form
8928 and its instructions, such as
legislation enacted after they were
published, go to www.irs.gov/form8928.

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
medical savings account (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 the
following.
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.

Sep 01, 2016

3. Any employer liable for the tax
under section 4980E for failure to make
comparable Archer MSA contributions
for all participating employees.
4. Any employer liable for the tax
under section 4980G for failure to make
comparable HSA contributions for all
participating employees.

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 section 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 4th 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
Send Form 8928 to 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
Cat. No. 52470C

“timely mailing as timely filing/paying”
rule for tax returns and payments.
These private delivery services include
only the following.
DHL Express (DHL): DHL Express
9:00, DHL Express 10:30, DHL Express
12:00, DHL Express Worldwide, DHL
Express Envelope, DHL Import Express
10:30, DHL Import Express 12:00, and
DHL Import Express Worldwide.
Federal Express (FedEx): FedEx First
Overnight, FedEx Priority Overnight,
FedEx Standard Overnight, FedEx
2Day, FedEx International Next Flight
Out, FedEx International Priority, FedEx
International First, and FedEx
International Economy.
United Parcel Service (UPS): UPS
Next Day Air Early AM, UPS Next Day
Air, UPS Next Day Air Saver, UPS 2nd
Day Air, UPS 2nd Day Air 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.
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, state or province,
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; or
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, state or
province, 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
-2-

ended March 31, 2016, should be
shown as 03/31/2016.
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.

!

CAUTION

If the plan number is not
provided, this will cause a delay
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 Use Only. A paid
preparer must sign Form 8928 and
provide the information in the Paid
Preparer Use Only section at the end of
the form if the preparer was paid to
prepare the form and is not an
employee of the filing entity. The
preparer must give you a copy of the
form in addition to the copy to be filed
with the IRS.
If you are a paid preparer, enter your
Preparer Tax Identification Number
(PTIN) in the space provided. Include
your complete address. If you work for a
firm, you also must enter the firm’s
name and the EIN of the firm. However,
you cannot use the PTIN of the tax
preparation firm in place of your PTIN.
You can apply for a PTIN online or by
filing Form W-12, IRS Paid Preparer Tax
Identification Number (PTIN)
Application and Renewal. For more
information about applying for a PTIN
online, visit the IRS website at
www.irs.gov/ptin.

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.

employed fewer than 20 employees on
a typical business day.
Any governmental plan under section
414(d).
Any church plan under section
414(e).

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.

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

Write “Summary Form” at the top to
indicate that this is a summary form and
attach all copies to it.
You may report all failures on
TIP the same form if the failures
occurred during the same tax
year.
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

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
6 months after the last day of the
maximum continuation coverage period
under the qualifying event that led to the
failure.
The noncompliance period may

TIP include portions of more than 1

plan year (in the case of an
employee benefit plan) or 1 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 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
-3-

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
million for all plans for failures due to
reasonable cause and not to willful
neglect. For those entities, do not enter
more than $2 million 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 million.

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
6 months after the last day of the
maximum continuation coverage period
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

TIP include portions of more than 1

plan year (in the case of an
employee benefit plan) or 1 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 income
-4-

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.

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

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.

Part III. Tax on Failure To
Make Comparable Archer
MSA Contributions Under
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.
“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.

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

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' HSAs 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 V. Tax Due
Make your check or money
order payable to “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.
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

-5-

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:
Recordkeeping . . .

12 hr., 40 min.

Learning about
the law or the
form . . . . . . . . . . .

4 hr., 0 min.

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

6 hr., 47 min.

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