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38928
Return of Certain Excise Taxes Under
Form
Chapter 43 of the Internal Revenue Code
OMB No. 1545-2148
(June 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 identifying number (see instructions)
Employer identification number (EIN)
Social security number (SSN)
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
H
Are you claiming a limitation of penalty under Parts I or II due to unintentional failure? If so, check here
Part I
Tax on Failure To Satisfy Continuation Coverage Requirements Under Section 4980B
Complete a separate Part I, lines 1 through 6, for each qualifying event for which one or more failures to satisfy
continuation coverage requirements that occured during the reporting period. (see instructions)
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 occured 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
4
If the failure was discovered after notice of examination sent, enter $2,500. Otherwise, enter -0-
5
5
To the extent the violations were more than de minimis, enter $15,000. Otherwise, enter -0-
6
6
Enter the largest of lines 3, 4, or 5
7
If there was more than one qualifying event, add the amounts shown on line 6 of all forms, and
enter the total on a single “summary” form. Otherwise, enter the amount from line 6 above. For a
third-party administrator, HMO, or insurance company, do not include more than $2,000,000 for
all unintentional failures (see instructions)
7
8
8
Enter the aggregate amount paid during the preceding tax year for group health plans
9
9
Multiply line 8 by 10% (.10)
10
500,000
10
Amount from section 4980B(c)(4)
11
Total tax due under section 4980B. If the failure was unintentional, enter the smallest of lines 7,
11
9, or 10. Otherwise, enter the amount from line 7
Part II
Tax on Failure To Meet Portability, Access, and Renewability Requirements Under Section 4980D
Complete a separate Part II, lines 12 through 18, for each failure to meet certain group health plan requirements that
occured during the reporting period. (see instructions)
12
12
Enter the total number of days of noncompliance in the reporting period
13
13
Enter the number of individuals to whom the failure applies
14
14
Multiply line 12 by line 13
15
15
Multiply line 14 by $100
16
16
If the failure was discovered after notice of examination sent, enter $2,500. Otherwise, enter -0-
17
17
To the extent the violations were more than de minimis, enter $15,000. Otherwise, enter -0-
18
18
Enter the largest of lines 15, 16, or 17
19
If there was more than one failure, add the amounts shown on line 18 of all forms, and enter the
19
total on a single “summary” form. Otherwise, enter the amount from line 18 above
20
20
Enter the aggregate amount paid during the preceding tax year for group health plans
21
21
Multiply line 20 by 10% (.10)
22
500,000
22
Amount from section 4980D(c)(3)
23
Total tax due under section 4980D. If the failure was unintentional, enter the smallest of lines 19,
21, or 22. Otherwise, enter the amount from line 19
23
8928
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Cat. No. 37742T
Form
(6-2009)
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