Federal Free Printable Form 8928 (Rev. May 2016) for 2017 Federal Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code

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Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code
Form 8928 (Rev. May 2016)

Form 8928 (Rev. May 2016) Department of the Treasury Internal Revenue Service Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code ▶ Information about Form 8928 and its separate instructions is at www.irs.gov/form8928. Filer's tax year beginning A OMB No. 1545-2146 (Under sections 4980B, 4980D, 4980E, and 4980G) and ending , , B Filer’s employer identification number (EIN) Name of filer (see instructions) 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 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 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 . . . . . . . . . 3 4 5 6 7 8 Multiply line 8 by 10% (0.10) . . . . . . . . . . . . . . . . . . . . . . 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 12 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 . . 14 15 Section C – Total Tax Due Under Section 4980B 16 Add lines 11 and 15 . . . . . . . . For Paperwork Reduction Act Notice, see instructions. . . . . . . . . . . . . . . . Cat. No. 37742T . ▶ 126 16 Form 8928 (Rev. 5-2016) Page 2 Form 8928 (Rev. 5-2016) 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% (0.10) . . . . Amount from section 4980D(c)(3) . . . Enter the smallest of lines 24, 26, or 27 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 . . . . . . . . . . . 17 . 20 . . . corrected go to line . . . . . . . . . 21 22 23 24 26 27 28 . . . 500,000 Section B – Failures Due to Willful Neglect or Otherwise Not Due to Reasonable Cause 29 30 31 32 33 29 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 . . 32 33 Section C – Total Tax Due Under Section 4980D 34 Add lines 28 and 33 Part III 35 36 . . . . . . . . . . . . . . . . . . . . . . ▶ . . . . . . ▶ . . . . . . . . . . ▶ 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 . . . . . . . . . . . . . . . 39 40 41 42 . 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 ▲ ▲ ▲ 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% (0.35) . . . . 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% (0.35) . . . . . . Part IV 37 38 . Telephone number Date Check if self-employed Firm's name ▶ Firm's EIN Firm's address ▶ Phone no. Date PTIN ▶ Form 8928 (Rev. 5-2016)
Extracted from PDF file 2016-federal-form-8928.pdf, last modified May 2016

More about the Federal Form 8928 Other TY 2016

We last updated the Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code in May 2017, so this is the latest version of Form 8928, fully updated for tax year 2016. You can download or print current or past-year PDFs of Form 8928 directly from TaxFormFinder. 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 8928 from the Internal Revenue Service in May 2017.

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Historical Past-Year Versions of Federal Form 8928

We have a total of five past-year versions of Form 8928 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2016 Form 8928

Form 8928 (Rev. May 2016)

Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code 2015 Form 8928

Form 8928 (Rev. December 2013)

Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code 2013 Form 8928

Form 8928 (Rev. December 2013)

Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code 2012 Form 8928

Form 8928 (Rev. September 2011)

Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code 2011 Form 8928

Form 8928 (Rev. September 2011)


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