Form 8928 - Return Of Certain Excise Taxes Under Chapter 43 Of The Internal Revenue Code Page 2
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Form 8928 (12-2009)
Page
Name of filer:
Filer’s EIN:
Part II
Tax on Failure To Meet Portability, Access, and Renewability 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
17
17
Enter the total number of days of noncompliance in the reporting period
18
Enter the number of individuals to whom the failure applies
18
19
19
Multiply line 17 by line 18
20
20
Multiply line 19 by $100
21
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 22.
21
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 day a notice of examination was sent, enter -0-
22
23
23
Enter the smaller of line 20 or line 22
24
If there was more than one failure, add the amounts shown on line 23 of all forms, and enter the
24
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
25
26
26
Multiply line 25 by 10% (.10)
500,000
27
27
Amount from section 4980D(c)(3)
28
28
Enter the smallest of lines 24, 26, or 27.
Section B – Failures Due to Willful Neglect or Otherwise Not Due to Reasonable Cause
29
29
Enter the total number of days of noncompliance in the reporting period
30
Enter the number of individuals to whom the failure applies
30
31
31
Multiply line 29 by line 30
32
32
Multiply line 31 by $100
33
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
33
Section C – Total Tax Due Under Section 4980D
34
Add lines 28 and 33
34
Part III
Tax on Failure To Make Comparable Archer MSA Contributions Under Section 4980E
35
35
Aggregate amount contributed to Archer MSAs of employees within calendar year
Total tax due under section 4980E. Multiply line 35 by 35% (.35)
36
36
Part IV
Tax on Failure To Make Comparable HSA Contributions Under Section 4980G
37
37
Aggregate amount contributed to HSAs of employees within calendar year
Total tax due under section 4980G. Multiply line 37 by 35% (.35)
38
38
Part V
Tax Due or Overpayment
39
39
Add lines 16, 34, 36, and 38
40
40
Enter amount of tax paid with Form 7004
41
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
41
42
Overpayment. Subtract line 39 from line 40
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
Sign
has any knowledge.
Here
Your signature
Telephone number
Date
Check
Date
Preparer’s SSN or PTIN
Paid
Preparer’s
if self-
signature
employed
Preparer’s
Firm’s name (or
EIN
Use Only
yours, if self-employed),
address, and ZIP code
Phone no. (
)
8928
Form
(12-2009)
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