Instructions For Form 8928 (December 2009) printable pdf download

Department of the Treasury

Instructions for Form 8928

Internal Revenue Service

(December 2009)

Return of Certain Excise Taxes Under Chapter 43

of the Internal Revenue Code

Section references are to the Internal

e. Parity in mental health benefits

rule for tax returns and payments.

and substance use disorder benefits

These private delivery services include

Revenue Code unless otherwise noted.

under section 9812.

only the following:

General Instructions

•

3. Any employer liable for the tax

DHL Express (DHL): DHL Same Day

under section 4980E for failure to make

Service.

•

comparable Archer medical savings

Federal Express (FedEx): FedEx

Purpose of Form

account (MSA) contributions for all

Priority Overnight, FedEx Standard

File Form 8928 to report the tax due on

participating employees.

Overnight, FedEx 2Day, FedEx

the following failures by group health

4. Any employer liable for the tax

International Priority, and FedEx

plans or employers.

under section 4980G for failure to make

International First.

•

A failure to provide a level of

comparable health savings account

United Parcel Service (UPS): UPS

coverage of the costs of pediatric

(HSA) contributions for all participating

Next Day Air, UPS Next Day Air Saver,

vaccines (as defined in section 2612 of

employees.

UPS 2nd Day Air, UPS 2nd Day Air

the Public Health Services Act) that is

A.M., UPS Worldwide Express Plus,

not below the coverage provided as of

and UPS Worldwide Express.

When to File

May 1, 1993.

The private delivery service can tell

•

For a failure under section 4980B or

A failure to satisfy continuation

you how to get written proof of the

section 4980D, if the failure is by an

coverage requirements under section

mailing date.

employer or other person responsible

4980B.

•

for providing or administering benefits

A failure to meet portability, access,

Interest and Penalties

under the plan (such as an insurer or

and renewability requirements under

third-party administrator), file Form

section 4980D.

Interest. Interest is charged on taxes

8928 on or before the due date for filing

•

A failure to make comparable Archer

not paid by the due date even if an

the person’s federal income tax return.

MSA contributions under section

extension of time to file is granted.

If the failure under sections 4980B or

4980E.

Interest is also charged on penalties

•

section 4980D is by a multiemployer or

imposed from the due date, including

A failure to make comparable health

multiple employer plan, file Form 8928

extensions, to the date of payment for

savings account (HSA) contributions

on or before the last day of the seventh

under section 4980G.

failure to file, negligence, fraud, gross

month following the end of the plan

valuation overstatements, and

year.

Who Must File

substantial understatements of tax. The

For a failure under section 4980E or

interest rate is determined under

Form 8928 must be filed by:

section 4980G, file Form 8928 on or

section 6621.

1. Any employer, group health plan,

before the 15th day of the fourth month

Penalty for late filing of return. If

plan administrator, or plan sponsor

following the calendar year in which the

you do not file a return by the due date,

liable for the tax under section 4980B

noncomparable contributions were

including extensions, you may have to

for failure to provide the required level

made.

pay a penalty of 5% of the unpaid tax

of pediatric vaccine coverage or to offer

Extension. File Form 7004,

for each month or part of a month the

continuation coverage to a qualified

Application for Automatic Extension of

return is late, up to a maximum of 25%

beneficiary.

Time to File Certain Business Income

of the unpaid tax. The minimum penalty

2. Any employer or group health

Tax, Information, and Other Returns, to

for a return that is more than 60 days

plan liable for the tax under section

request an automatic extension of time

late is the smaller of the tax due or

4980D for failure to comply with the

to file Form 8928. You must file Form

$100. The penalty will not be imposed if

following group health plan

7004 on or before the regular due date

you can show that the failure to file on

requirements.

of Form 8928. See the instructions for

time was due to reasonable cause. If

a. Limitation on preexisting

Form 7004 for more information. Form

you file late, you must attach a

condition exclusions, certification of

7004 does not extend the time to pay

statement to Form 8928 explaining the

creditable coverage, and special

excise taxes due under Form 8928.

reasonable cause.

enrollment requirements under section

Where To File

Penalty for late payment of tax. If

9801.

you do not pay the tax when due, you

b. Nondiscrimination in eligibility to

may have to pay a penalty of

of 1%

enroll and premium contributions under

File Form 8928 at the following

of the unpaid tax for each month or part

section 9802.

address.

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

c. Guaranteed renewability to

maximum of 25% of the unpaid tax.

Department of the Treasury

employers in a multiemployer or

The penalty will not be imposed if you

Internal Revenue Service

multiple employer welfare arrangement

can show that the failure to pay on time

Cincinnati, OH 45999-0009

under section 9803.

was due to reasonable cause.

d. 48-hour and 96-hour hospital

Private delivery services. You can

length of stay in connection with

use certain private delivery services

Interest and penalties for late filing

childbirth for mothers and newborns

designated by the IRS to meet the

and late payment will be billed

under section 9811.

“timely mailing as timely filing/paying”

separately after the return is filed.

Cat. No. 52470C

Instructions For Form 8928 (December 2009)

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