Form 8928 Draft - Return Of Certain Excise Taxes Under Chapter 43 Of The Internal Revenue Code Page 3

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2
Form 8928 (6-2009)
Page
Name of filer:
Filer’s identifying number:
Part III
Tax on Failure To Make Comparable Archer MSA Contributions Under Section 4980E
24
24
Aggregate amount contributed to Archer MSAs of employees within calendar year
Total tax due under section 4980E. Multiply line 24 by 35% (.35)
25
25
Part IV
Tax on Failure To Make Comparable HSA Contributions Under Section 4980G
26
26
Aggregate amount contributed to HSAs of employees within calendar year
Total tax due under section 4980G. Multiply line 26 by 35% (.35)
27
27
Part V
Tax Due or Overpayment
28
28
Add lines 11, 23, 25, and 27
29
29
Enter amount of tax paid with Form 7004
30
Tax due. Subtract line 29 from line 28. If less than zero, enter -0-, and go to line 31. 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
30
31
Overpayment. Subtract line 28 from line 29
31
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
(6-2009)

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