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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

When To File

A.M., UPS Worldwide Express Plus,

Section references are to the Internal

and UPS Worldwide Express.

Revenue Code unless otherwise noted.

For a failure under section 4980B or

The private delivery service can tell

General Instructions

section 4980D, if the failure is by an

you how to get written proof of the

employer or other person responsible

mailing date.

for providing or administering benefits

Purpose of Form

under the plan (such as an insurer or

Interest and Penalties

third-party administrator), file Form

File Form 8928 to report the tax due on

8928 on or before the due date for filing

the following failures by group health

Interest. Interest is charged on taxes

the person’s federal income tax return.

plans or employers.

not paid by the due date even if an

•

extension of time to file is granted.

If the failure under sections 4980B or

A failure to provide a level of

Interest is also charged on penalties

section 4980D is by a multiemployer or

coverage of the costs of pediatric

imposed from the due date, including

multiple employer plan, file Form 8928

vaccines (as defined in section 2612 of

extensions, to the date of payment for

on or before the last day of the seventh

the Public Health Services Act) that is

failure to file, negligence, fraud, gross

month following the end of the plan

not below the coverage provided as of

valuation overstatements, and

year.

May 1, 1993.

substantial understatements of tax. The

•

A failure to satisfy continuation

For a failure under section 4980E or

interest rate is determined under

coverage requirements under section

section 4980G, file Form 8928 on or

section 6621.

4980B.

before the 15th day of the fourth month

Penalty for late filing of return. If

•

following the calendar year in which the

A failure to meet portability, access,

you do not file a return by the due date,

noncomparable contributions were

renewability, and market reform

including extensions, you may have to

made.

requirements under sections 9801,

pay a penalty of 5% of the unpaid tax

9802, 9803, 9811, 9812, 9813, and

Extension. File Form 7004,

for each month or part of a month the

9815.

Application for Automatic Extension of

return is late, up to a maximum of 25%

•

A failure to make comparable Archer

Time to File Certain Business Income

of the unpaid tax. The minimum penalty

Tax, Information, and Other Returns, to

MSA contributions under section

for a return that is more than 60 days

request an automatic extension of time

4980E.

late is the smaller of the tax due or

to file Form 8928. You must file Form

•

$100. The penalty will not be imposed if

A failure to make comparable health

7004 on or before the regular due date

you can show that the failure to file on

savings account (HSA) contributions

of Form 8928. See the instructions for

time was due to reasonable cause. If

under section 4980G.

Form 7004 for more information. Form

you file late, you must attach a

Who Must File

7004 does not extend the time to pay

statement to Form 8928 explaining the

excise taxes due under Form 8928.

reasonable cause.

Form 8928 must be filed by:

Penalty for late payment of tax. If

Where To File

1. Any employer, group health plan,

you do not pay the tax when due, you

plan administrator, or plan sponsor

may have to pay a penalty of

of 1%

liable for the tax under section 4980B

File Form 8928 at the following

of the unpaid tax for each month or part

for failure to provide the required level

address.

of a month the tax is not paid, up to a

of pediatric vaccine coverage or to offer

maximum of 25% of the unpaid tax.

continuation coverage to a qualified

Department of the Treasury

The penalty will not be imposed if you

beneficiary.

Internal Revenue Service

can show that the failure to pay on time

Cincinnati, OH 45999-0009

2. Any employer or group health

was due to reasonable cause.

plan liable for the tax under section

Interest and penalties for late filing

Private delivery services. You can

4980D for failure to meet portability,

and late payment will be billed

use certain private delivery services

access, renewability, and market reform

separately after the return is filed.

designated by the IRS to meet the

requirements for group health plans

“timely mailing as timely filing/paying”

Claim for Refund or

under sections 9801, 9802, 9803, 9811,

rule for tax returns and payments.

9812, 9813, and 9815.

These private delivery services include

Credit/Amended Return

only the following:

3. Any employer liable for the tax

•

DHL Express (DHL): DHL Same Day

File an amended Form 8928 for any of

under section 4980E for failure to make

Service.

the following:

comparable Archer medical savings

•

Federal Express (FedEx): FedEx

To claim a refund of overpaid taxes

account (MSA) contributions for all

Priority Overnight, FedEx Standard

reportable on Form 8928;

participating employees.

•

Overnight, FedEx 2Day, FedEx

To receive a credit for overpaid

4. Any employer liable for the tax

International Priority, and FedEx

taxes; or

under section 4980G for failure to make

•

International First.

To report additional taxes due within

comparable health savings account

•

United Parcel Service (UPS): UPS

the same tax year of the filer if those

(HSA) contributions for all participating

Next Day Air, UPS Next Day Air Saver,

taxes have the same due date as those

employees.

UPS 2nd Day Air, UPS 2nd Day Air

previously reported.

Sep 16, 2011

Cat. No. 52470C

Instructions For Form 8928 - (September 2011) Return Of Certain Excise Taxes Under Chapter 43 Of The Internal Revenue Code

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