Form 14199 - Cobra Recapture Statement
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1Department of the Treasury — Internal Revenue Service
14199
Form
COBRA Recapture Statement
2011
(January
)
Complete the following information
Taxpayer Name
Social Security Number
Daytime telephone number
(including area code)
(
)
-
Complete the following information
I,
, under penalties of perjury, certify that I did not meet the
(Print Name)
requirements, as explained in the enclosed letter and Publication 502, for recapturing COBRA premium
assistance, for the 2009 tax year.
I did not meet the requirements because:
NOTE: If you are not required to recapture your COBRA premium assistance because of the modified adjusted gross
income calculation, please send us a completed copy of the worksheet for Recapture of COBRA Premium Assistance for
Higher Income Taxpayers (also included with the letter), when you send us this completed Form.
Signature
Date
14199
Catalog Number 57048S
Form
(Rev. 1-2011)
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