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Federal Free Printable Form 14199 (Rev. 1-2011) for 2020 Federal COBRA Recapture Statement

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COBRA Recapture Statement
Form 14199 (Rev. 1-2011)

Department of the Treasury — Internal Revenue Service Form 14199 (January 2011) COBRA Recapture Statement Complete the following information Taxpayer Name Social Security Number Daytime telephone number (including area code) ( ) - Complete the following information , under penalties of perjury, certify that I did not meet the I, (Print Name) requirements, as explained in the enclosed letter and Publication 502, for recapturing COBRA premium assistance, for the 2009 tax year. I did not meet the requirements because: NOTE: If you are not required to recapture your COBRA premium assistance because of the modified adjusted gross income calculation, please send us a completed copy of the worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers (also included with the letter), when you send us this completed Form. Signature Catalog Number 57048S Date www.irs.gov Form 14199 (Rev. 1-2011)
Extracted from PDF file 2018-federal-form-14199.pdf, last modified January 2011

More about the Federal Form 14199 Other

We last updated the COBRA Recapture Statement in February 2019, and the latest form we have available is for tax year 2018. This means that we don't yet have the updated form for the current tax year. Please check this page regularly, as we will post the updated form as soon as it is released by the Federal Internal Revenue Service. You can print other Federal tax forms here.

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Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 14199 from the Internal Revenue Service in February 2019.

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Historical Past-Year Versions of Federal Form 14199

We have a total of six past-year versions of Form 14199 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:

2018 Form 14199

Form 14199 (Rev. 1-2011)

2017 Form 14199

Form 14199 (Rev. 1-2011)

2016 Form 14199

Form 14199 (Rev. 1-2011)

COBRA Recapture Statement 2015 Form 14199

Form 14199 (Rev. 1-2011)

COBRA Recapture Statement 2012 Form 14199

Form 14199 (Rev. 1-2011)

COBRA Recapture Statement 2011 Form 14199

Form 14199 (Rev. 1-2011)

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