Form 8453-R - Declaration And Signature For Electronic Filing Of Forms 8947 And 8963
Download a blank fillable Form 8453-R - Declaration And Signature For Electronic Filing Of Forms 8947 And 8963 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 8453-R - Declaration And Signature For Electronic Filing Of Forms 8947 And 8963 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
18453-R
Declaration and Signature for Electronic Filing of
Form
Forms 8947 and 8963
(January 2014)
OMB No. 1545-2253
Information about Form 8453-R and its instructions is at
▶
Department of the Treasury
For calendar year 20
Internal Revenue Service
Name of organization
Employer identification number
Part I
Type of Report
Check the box for the type of report being filed with Form 8453-R.
Form 8947 check here.
Do not check more than one box in Part I.
Form 8963 check here.
Part II
Declaration of Officer
Under penalties of perjury, I declare that I have examined the electronic report, including accompanying statements, and, to the best of my knowledge and belief,
it is true, correct, and complete. If I am signing as the designated entity, I also declare that the above named entity is the agent of an affiliated group or other
designated entity (as per the instructions). I understand that the designated entity will receive IRS communications relating to the fee imposed by ACA section
9008 or 9010 and is to pay this fee to the IRS on behalf of the controlled group. Each entity that is a member of the controlled group is jointly and severally liable
for this fee. I further declare that each entity in the controlled group identified on the electronic report consents to the choice of the designated entity indicated on
that report. I further certify that I am an officer of the single-person covered entity or the designated entity, and that I am duly authorized to sign this report on
behalf of that covered entity. Each member of the controlled group that is a covered entity as of the end of the day on December 31, 2013, is jointly and severally
liable for any applicable penalty under ACA section 9010. (Where the designated entity is selected by the IRS, each entity in this report is deemed to consent to
the choice of designated entity.)
Sign
Here
Signature of officer
Date
Title
Print name of signing official
Daytime telephone number
Fax number
• The president, vice president, treasurer, assistant treasurer, chief
Future Developments
accounting officer, or
For the latest information about developments related to Form
• Any other officer of the organization, such as an officer of the
8453-R and its instructions, such as legislation enacted after they
single-person covered entity or the designated entity, authorized to
were published, go to
sign the organization's report.
Purpose of Form
Paperwork Reduction Act Notice. We ask for the information on this
form to carry out the Internal Revenue laws of the United States. You
Use Form 8453-R to authenticate the electronic filing of:
are required to give us the information. We need it to ensure that you
• Form 8947, Report of Branded Prescription Drug Information, and
are complying with these laws and to allow us to figure and collect the
• Form 8963, Report of Health Insurance Provider Information.
right amount of fees.
You are not required to provide the information requested on a form
Who Must File
that is subject to the Paperwork Reduction Act unless the form displays
If you are filing a Form 8947 or Form 8963 in 2014, you must upload
a valid OMB control number. Books or records relating to a form or its
Form 8453-R with your electronically filed report.
instructions must be retained as long as their contents may become
material in the administration of any Internal Revenue law. The rules
When To File
governing the confidentiality of this form are covered in Internal
Revenue Code section 6103.
Form 8453-R must be filed with your electronically filed Form 8947
or your Form 8963.
The time needed to complete and file this form will vary
How To File
depending on individual circumstances. The estimated average time
is:
File Form 8453-R with the organization's electronically filed report.
Use a scanner to create a PDF file of the completed form and
Recordkeeping .
.
.
.
.
.
.
.
.
.
.
. 1 hr., 12 min.
upload it with your Form 8947 or your Form 8963.
Learning about the law or the form
.
.
.
.
.
.
. 12 min.
Part II. Declaration of Officer
Preparing and sending the form
.
.
.
.
.
.
.
. 13 min.
If you have comments concerning the accuracy of these time
An electronically transmitted report will not be considered complete
(and therefore not considered filed) unless Form 8453-R is signed
estimates or suggestions for making this form simpler, we would be
by an officer of the organization, scanned into a PDF file, and
happy to hear from you. You can send us comments from
transmitted with the report.
Click on “More Information” and then on
The officer's signature allows the IRS to disclose to the
“Give us feedback.” You can also write to:
transmitter:
Internal Revenue Service
• An acknowledgement that the IRS has accepted the
Tax Forms and Publications
organization's electronically filed report, and
1111 Constitution Ave. NW, IR-6526
Washington, DC 20224
• The reason(s) for a delay in processing the report.
Do not send the form to this office. Instead, see How To File,
The declaration of officer must be signed and dated by:
earlier.
8453-R
For Paperwork Reduction Act Notice, see instructions.
Form
(1-2014)
Cat. No. 60914Z
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 8453-f - U.s. Estate Or Trust Income Tax Declaration And Signature For Electronic Filing - 2013
Financial
Form 8453-f - U.s. Estate Or Trust Income Tax Declaration And Signature For Electronic Filing - 2013
Financial
Related Categories
Parent category: Financial