Instructions For Form 8928 (December 2009) Page 3
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Termination or reduction of hours of
reasonable diligence would have
reasonable cause, complete Part I,
the covered employee’s employment
known, that the failure occurred.
Section B, lines 12 through 15.
(other than for employee gross
Additionally, no tax is due if the failure
Line 12. Calculate the total number of
misconduct).
under Part I, Section A was due to
days of noncompliance within the
•
Divorce or legal separation of the
reasonable cause and not due to willful
reporting period beginning on the date
covered employee from the employee’s
neglect and the failure was corrected
the failure first occurred and ending on
spouse.
during the 30-day period beginning on
the earlier of the date the failure is
•
Covered employee becoming entitled
the 1st date anyone liable for the tax
corrected or, at the latest, a date that is
to Medicare benefits.
knew, or exercising reasonable
six months after the last day of the
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Dependent child of the covered
diligence should have known, that the
maximum continuation coverage period
employee ceasing to be a covered child
failure existed.
under the qualifying event that led to
under the terms of the plan.
For this purpose, a failure is treated
the failure.
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Bankruptcy of the employer from
as corrected if the failure is retroactively
Line 15. If you had more than one
whose employment the covered
undone to the extent possible and the
qualifying event during the reporting
employee retired.
qualified beneficiary to whom the failure
period, complete lines 12 through 14 in
Waiver of excise tax. The Secretary
relates is placed in a financial position
a separate Part I, Section B for each
may waive part or all of the excise tax
which is as good as such beneficiary
qualifying event and enter the total from
under Part I, to the extent that payment
would have been in had the failure not
line 14 from all copies of Part I, Section
of the tax would be excessive relative
occurred.
B on line 15 of your summary form. See
to the failure involved. This only applies
Line 5. The minimum excise tax under
the discussion under Part I earlier.
to failures due to reasonable cause and
Part I, Section A is $2,500 for each
not due to willful neglect.
qualified beneficiary for whom one or
Part II. Tax on Failure To
Note. The tax under Part I will not
more failures occurred if the failure or
Meet Portability, Access,
apply to the following.
failures were not corrected before the
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Any failure of a group health plan if
date a notice of examination of income
and Renewability
the qualifying event occurred during the
tax liability was sent from the IRS and
calendar year immediately following a
the failure or failures continued during
Requirements Under
calendar year during which all
the examination period. The minimum
Section 4980D
employers maintaining the plan
excise tax under Part I, Section A is
normally employed fewer than 20
$15,000 if the failure or failures are
Complete a separate Part II, Section A,
employees on a typical business day.
determined to be more than de minimis.
lines 17 through 23 for each failure to
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Any governmental plan under section
Line 7. If you had more than one
meet portability, access, and
414(d).
qualifying event during the reporting
renewability requirements that occurred
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Any church plan under section
period, complete lines 1 through 6 in a
during the reporting period that was
414(e).
separate Part I, Section A for each
due to reasonable cause and not to
qualifying event and enter the total from
willful neglect. If multiple such failures
Section A—Failures Due to
line 6 from all copies of Part I, Section
occurred with different noncompliance
Reasonable Cause and Not
A on line 7 of your summary form. See
periods, complete lines 17 through 23
to Willful Neglect
the discussion under Part I earlier.
in a separate Part I, Section A for each
failure. Then complete a “summary”
Line 8. For a single employer plan,
If the failure or failures as a result of a
Form 8928 with items A through G and
enter on line 8 the aggregate amount
particular qualifying event were due to
enter the total amount of the excise tax
paid or incurred during the preceding
reasonable cause and not to willful
on line 24 of that summary form and
tax year by the employer (or a
neglect, complete Part I, Section A,
complete lines 25 through 28 for all
predecessor) for its group health plan.
lines 1 through 11.
failures due to reasonable cause and
For a multiemployer plan, enter on this
Line 1. Calculate the total number of
not to willful neglect.
line the amount paid or incurred during
days of noncompliance within the
the current tax year to provide medical
Complete a separate Part II, Section
reporting period beginning on the date
care, directly or through insurance or
B, lines 29 through 33, for each failure
the failure first occurred and ending on
reimbursement.
to meet portability, access, and
the earlier of the date the failure is
Line 11. The maximum excise tax
renewability requirements that occurred
corrected or, at the latest, a date that is
payable during a tax year by third-party
during the reporting period that was
six months after the last day of the
administrators, HMOs, and insurance
due to willful neglect or otherwise not
maximum continuation coverage period
companies under Part I, Section A is
due to reasonable cause. If multiple
under the qualifying event that led to
$2,000,000 for all plans for failures due
failures occurred with different
the failure.
to reasonable cause not to willful
noncompliance periods, complete lines
The noncompliance period may
neglect. For those entities, do not enter
29 through 32 on a separate Part II,
TIP
include portions of more than
more than $2,000,000 on this line for
Section B for each failure. Then
one plan year (in the case of an
such failures for all plans even if the
complete a “summary” Form 8928 with
employee benefit plan) or one tax year
aggregate excise tax owed for all
items A through G and enter the total
(in the case of an employer or
failures under Part I, Section A is more
amount of the excise tax on line 33 of
third-party administrator). In that case,
than $2,000,000.
that summary form for all such failures.
only the portion of the noncompliance
Write “Summary Form” at the top to
Section B—Failures Due to
period falling within that plan year or tax
indicate that this is a summary form
year would be used to calculate the
Willful Neglect or Otherwise
and attach all copies to it.
excise tax due for that year.
Not Due to Reasonable
Line 4. No tax is due for any failure
Waiver of excise tax. The Secretary
Cause
under Part I, Section A if it is
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
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