8928
Return of Certain Excise Taxes Under
Form
Chapter 43 of the Internal Revenue Code
OMB No. 1545-2148
(December 2009)
Department of the Treasury
(Under sections 4980B, 4980D, 4980E, and 4980G)
Internal Revenue Service
Filer tax year beginning
,
and ending
,
A
Name of filer (see instructions)
B
Filer’s employer identification
number (EIN)
Number, street, and room or suite no. (If a P.O. box, see instructions)
City or town, state, and ZIP 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
1
Enter the total number of days of noncompliance in the reporting period
2
Enter the number of qualified beneficiaries for which a failure occurred as a
2
result of this qualifying event
3
If you entered 2 or more on line 2, multiply line 1 by $200. Otherwise, multiply line 1 by $100
3
4
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 then go to line 5.
Otherwise, enter the amount from line 3 on line 6 and go to line 7
4
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 day a notice of examination was sent, enter -0-
5
6
6
Enter the smaller of line 3 or line 5
7
If there was more than one qualifying event, add the amounts shown on line 6 of all forms, and
7
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
8
current tax year for a multiemployer health plan to provide medical care
9
9
Multiply line 8 by 10% (.10)
10
500,000
10
Amount from section 4980B(c)(4)
11
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
11
Section B – Failures Due to Willful Neglect or Otherwise Not Due to Reasonable Cause
12
12
Enter the total number of days of noncompliance in the reporting period
13
Enter the number of qualified beneficiaries for which a failure occurred as
13
a result of this qualifying event
14
14
If you entered 2 or more on line 13, multiply line 12 by $200. Otherwise, multiply line 12 by $100
15
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
15
Section C – Total Tax Due Under Section 4980B
16
16
Add lines 11 and 15
8928
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Cat. No. 37742T
Form
(12-2009)