Form 8928 - Return Of Certain Excise Taxes Under Chapter 43 Of The Internal Revenue Code
Download a blank fillable Form 8928 - Return Of Certain Excise Taxes Under Chapter 43 Of The Internal Revenue Code in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 8928 - Return Of Certain Excise Taxes Under Chapter 43 Of The Internal Revenue Code with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
28928
Return of Certain Excise Taxes Under
Form
Chapter 43 of the Internal Revenue Code
OMB No. 1545-2148
(Rev. December 2013)
(Under sections 4980B, 4980D, 4980E, and 4980G)
Department of the Treasury
Information about Form 8928 and its separate instructions is at
Internal Revenue Service
▶
Filer's tax year beginning
and ending
,
,
A
Name of filer (see instructions)
B Filer’s employer identification
number (EIN)
Number, street, and room or suite no. (if a P.O. box, see instructions)
City or town, state or province, country, and ZIP or foreign postal 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
Part I
Tax on Failure To Satisfy Continuation Coverage Requirements Under Section 4980B
Complete a separate Part I, lines 1 through 6, for failures due to reasonable cause and not to willful neglect, and a
separate Part I, lines 12 through 14, for other failures, for each qualifying event for which one or more failures to
satisfy continuation coverage 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
1
Enter the total number of days of noncompliance in the reporting period .
.
.
.
.
.
.
1
2
Enter the number of qualified beneficiaries for which a failure occurred
as a result of this qualifying event .
.
.
.
.
.
.
.
.
.
.
.
2
3
If you entered 2 or more on line 2, multiply line 1 by $200. Otherwise, multiply line 1 by $100
3
4
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 5.
Otherwise, enter the amount from line 3 on line 6 and go to line 7
.
.
.
.
.
.
.
.
.
4
5
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- .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
5
6
Enter the smaller of line 3 or line 5 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
6
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 .
7
8
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 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
8
9
Multiply line 8 by 10% (.10) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
9
10
10
Amount from section 4980B(c)(4) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
500,000
11
Enter the smallest of lines 7, 9, or 10. For a third-party administrator, HMO, or insurance
company, the amount you enter on this line filed for all plans you administer during the same
tax year cannot exceed $2 million; reduce the amount you would otherwise enter on this line to
the extent the amount for all plans would exceed this limit .
.
.
.
.
.
.
.
.
.
.
.
11
Section B – Failures Due to Willful Neglect or Otherwise Not Due to Reasonable Cause
12
Enter the total number of days of noncompliance in the reporting period .
.
.
.
.
.
.
12
13
Enter the number of qualified beneficiaries for which a failure occurred
as a result of this qualifying event .
.
.
.
.
.
.
.
.
.
.
.
13
14
If you entered 2 or more on line 13, multiply line 12 by $200. Otherwise, multiply line 12 by $100.
14
15
If there was more than one qualifying event, add the amounts shown on line 14 of all forms, and
enter the total on a single “summary” form. Otherwise, enter the amount from line 14 above .
.
15
Section C – Total Tax Due Under Section 4980B
16
126
16
Add lines 11 and 15
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
▶
8928
For Paperwork Reduction Act Notice, see instructions.
Form
(Rev. 12-2013)
Cat. No. 37742T
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 8928 Draft - Return Of Certain Excise Taxes Under Chapter 43 Of The Internal Revenue Code
Financial
Instructions For Form 8928 - (september 2011) Return Of Certain Excise Taxes Under Chapter 43 Of The Internal Revenue Code
Financial
Instructions For Form 8928 - Return Of Certain Excise Taxes Under Chapter 43 Of The Internal Revenue Code - 2016
Financial
Related Categories
Parent category: Financial