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Bankruptcy of the employer from

For this purpose, a failure is treated

under the qualifying event that led to

whose employment the covered

as corrected if the failure is retroactively

the failure.

employee retired.

undone to the extent possible and the

Line 15. If you had more than one

qualified beneficiary to whom the failure

Waiver of excise tax. The Secretary

qualifying event during the reporting

relates is placed in a financial position

period, complete lines 12 through 14 in

may waive part or all of the excise tax

which is as good as such beneficiary

under Part I, to the extent that payment

a separate Part I, Section B for each

would have been in had the failure not

of the tax would be excessive relative

qualifying event and enter the total from

occurred.

to the failure involved. This only applies

line 14 from all copies of Part I, Section

to failures due to reasonable cause and

Line 5. The minimum excise tax under

B on line 15 of your summary form. See

not due to willful neglect.

Part I, Section A is $2,500 for each

the discussion under Part I earlier.

qualified beneficiary for whom one or

Note. The tax under Part I will not

Part II. Tax on Failure To

more failures occurred if the failure or

apply to the following.

failures were not corrected before the

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Any failure of a group health plan if

Meet Portability, Access,

date a notice of examination of income

the qualifying event occurred during the

tax liability was sent from the IRS and

and Renewability

calendar year immediately following a

the failure or failures continued during

calendar year during which all

Requirements Under

the examination period. The minimum

employers maintaining the plan

excise tax under Part I, Section A is

normally employed fewer than 20

Section 4980D

$15,000 if the failure or failures are

employees on a typical business day.

determined to be more than de minimis.

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Complete a separate Part II, Section A,

Any governmental plan under section

lines 17 through 23 for each failure to

414(d).

Line 7. If you had more than one

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meet portability, access, and

Any church plan under section

qualifying event during the reporting

renewability requirements that occurred

414(e).

period, complete lines 1 through 6 in a

during the reporting period that was

separate Part I, Section A for each

due to reasonable cause and not to

Section A—Failures Due to

qualifying event and enter the total from

willful neglect. If multiple such failures

line 6 from all copies of Part I, Section

Reasonable Cause and Not

occurred with different noncompliance

A on line 7 of your summary form. See

to Willful Neglect

periods, complete lines 17 through 23

the discussion under Part I earlier.

in a separate Part I, Section A for each

If the failure or failures as a result of a

Line 8. For a single employer plan,

failure. Then complete a “summary”

particular qualifying event were due to

enter on line 8 the aggregate amount

Form 8928 with items A through G and

reasonable cause and not to willful

paid or incurred during the preceding

enter the total amount of the excise tax

neglect, complete Part I, Section A,

tax year by the employer (or a

on line 24 of that summary form and

lines 1 through 11.

predecessor) for its group health plan.

complete lines 25 through 28 for all

Line 1. Calculate the total number of

For a multiemployer plan, enter on this

failures due to reasonable cause and

days of noncompliance within the

line the amount paid or incurred during

not to willful neglect.

reporting period beginning on the date

the current tax year to provide medical

Complete a separate Part II, Section

the failure first occurred and ending on

care, directly or through insurance or

B, lines 29 through 33, for each failure

the earlier of the date the failure is

reimbursement.

to meet portability, access, and

corrected or, at the latest, a date that is

Line 11. The maximum excise tax

renewability requirements that occurred

six months after the last day of the

payable during a tax year by third-party

during the reporting period that was

maximum continuation coverage period

administrators, HMOs, and insurance

due to willful neglect or otherwise not

under the qualifying event that led to

companies under Part I, Section A is

due to reasonable cause. If multiple

the failure.

$2,000,000 for all plans for failures due

failures occurred with different

to reasonable cause not to willful

The noncompliance period may

noncompliance periods, complete lines

neglect. For those entities, do not enter

include portions of more than

TIP

29 through 32 on a separate Part II,

more than $2,000,000 on this line for

one plan year (in the case of an

Section B for each failure. Then

such failures for all plans even if the

employee benefit plan) or one tax year

complete a “summary” Form 8928 with

aggregate excise tax owed for all

(in the case of an employer or

items A through G and enter the total

failures under Part I, Section A is more

third-party administrator). In that case,

amount of the excise tax on line 33 of

than $2,000,000.

only the portion of the noncompliance

that summary form for all such failures.

period falling within that plan year or tax

Section B—Failures Due to

Write “Summary Form” at the top to

year would be used to calculate the

indicate that this is a summary form

Willful Neglect or Otherwise

excise tax due for that year.

and attach all copies to it.

Not Due to Reasonable

Line 4. No tax is due for any failure

Waiver of excise tax. The Secretary

under Part I, Section A if it is

Cause

may waive part or all of the excise tax

established to the satisfaction of the

If the failure or failures as a result of a

under Part II, to the extent that payment

Secretary of the Treasury that no one

particular qualifying event were due to

of the tax would be excessive relative

liable for the tax knew, or exercising

willful neglect or otherwise not due to

to the failure involved. This only applies

reasonable diligence would have

reasonable cause, complete Part I,

to failures due to reasonable cause and

known, that the failure occurred.

Section B, lines 12 through 15.

not due to willful neglect.

Additionally, no tax is due if the failure

under Part I, Section A was due to

Line 12. Calculate the total number of

Exception for certain insured small

reasonable cause and not due to willful

days of noncompliance within the

employer plans. If you are a small

neglect and the failure was corrected

reporting period beginning on the date

employer who provides health

during the 30-day period beginning on

the failure first occurred and ending on

insurance coverage solely through a

the 1st date anyone liable for the tax

the earlier of the date the failure is

contract with a health insurance issuer,

knew, or exercising reasonable

corrected or, at the latest, a date that is

you will not be liable for the excise tax

diligence should have known, that the

six months after the last day of the

under Part II for any failure (other than

failure existed.

maximum continuation coverage period

a failure under section 9811) that is

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Instructions For Form 8928 - (September 2011) Return Of Certain Excise Taxes Under Chapter 43 Of The Internal Revenue Code Page 3

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