Form 8928 - Return Of Certain Excise Taxes Under Chapter 43 Of The Internal Revenue Code Page 2
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Form 8928 (Rev. 5-2016)
Page
Name of filer:
Filer’s EIN:
Part II
Tax on Failure To Meet Portability, Access, Renewability, and Other 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
For
IRS
Use
Only
17
Enter the total number of days of noncompliance in the reporting period .
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17
18
18
Enter the number of individuals to whom the failure applies
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19
19
Multiply line 17 by line 18 .
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20
Multiply line 19 by $100 .
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20
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 go to line
22. Otherwise, enter the amount from line 20 on line 23 and go to line 24 .
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21
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 date a notice of examination was sent, enter -0- .
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22
23
23
Enter the smaller of line 20 or line 22 .
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24
If there was more than one failure, add the amounts shown on line 23 of all forms, and enter
the total on a single “summary” form. Otherwise, enter the amount from line 23 above
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24
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 .
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25
26
26
Multiply line 25 by 10% (0.10) .
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27
Amount from section 4980D(c)(3) .
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27
500,000
28
Enter the smallest of lines 24, 26, or 27 .
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28
Section B – Failures Due to Willful Neglect or Otherwise Not Due to Reasonable Cause
29
Enter the total number of days of noncompliance in the reporting period .
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29
30
30
Enter the number of individuals to whom the failure applies
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31
31
Multiply line 29 by line 30 .
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32
Multiply line 31 by $100 .
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32
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
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Section C – Total Tax Due Under Section 4980D
34
127
34
Add lines 28 and 33
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▶
Part III
Tax on Failure To Make Comparable Archer MSA Contributions Under Section 4980E
35
Aggregate amount contributed to Archer MSAs of employees within calendar year .
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35
36
Total tax due under section 4980E. Multiply line 35 by 35% (0.35) .
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128
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 .
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38
137
38
Total tax due under section 4980G. Multiply line 37 by 35% (0.35) .
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Part V
Tax Due or Overpayment
39
Add lines 16, 34, 36, and 38 .
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39
40
Enter amount of tax paid with Form 7004
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40
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 .
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41
42
Overpayment. Subtract line 39 from line 40
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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
Print/Type preparer's name
Preparer's signature
Date
PTIN
Paid
Check
if
self-employed
Preparer
Use Only
Firm's name
Firm's EIN
▶
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Firm's address
Phone no.
▶
8928
Form
(Rev. 5-2016)
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