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Example. You entered “1,400.00” in column 4 on line 7,

For more information on the COBRA premium subsidy, visit

“-500.00” in column 4 on line 8, and “-100.00” in column 4 on

IRS.gov and enter “COBRA” in the search box.

line 10. Combine these amounts and enter “800.00” in column 4

19b. Number of Individuals Provided COBRA

on line 18.

Premium Assistance on line 19a

Line 7

1,400.00

Enter the total number of assistance eligible individuals provided

Line 8

-500.00

COBRA premium assistance in column 1. Count each

Line 10

-100.00

assistance eligible individual who paid a reduced COBRA

premium in the quarter as one individual, whether or not the

Line 18

800.00

reduced premium was for insurance that covered more than one

assistance eligible individual. For example, if the reduced

COBRA premium was for coverage for a former employee,

19a. Claiming or Correcting the COBRA

spouse, and two children, you would include one individual in

Premium Assistance Credit

the number entered on line 19b for the premium assistance

entered on line 19a. Further, each individual is reported only

The COBRA premium assistance credit was available

once per quarter. For example, an assistance eligible individual

to an employer for premiums paid on behalf of

who made monthly premium payments during the quarter would

employees who were involuntarily terminated from

only be reported as one individual on line 19b for that quarter.

CAUTION

employment between September 1, 2008 and May 31, 2010.

For tax periods ending before January 1, 2014, enter the

The COBRA premium assistance credit is not available for

number of assistance eligible individuals provided COBRA

individuals who were involuntarily terminated after May 31, 2010.

premium assistance previously reported on Form 941 or

Therefore, only in rare circumstances, such as instances where

941-SS, line 12b, in column 2. For tax periods beginning after

COBRA eligibility was delayed as a result of employer provided

December 31, 2013, enter -0- in column 2, unless you are

health insurance coverage following termination, will the credit

correcting a previously filed Form 941-X. If you or the IRS

be available.

previously corrected the number of individuals reported, the

Enter 65% of the total COBRA premium assistance payments for

number entered in column 2 should take into account all

all assistance eligible individuals in column 1. Report the

previous corrections.

premium assistance payments on this line only after the

assistance eligible individual's 35% share of the premium has

20. Total

been paid. For COBRA coverage provided under a self-insured

Combine the amounts on lines 18 and 19a of column 4 and enter

plan, COBRA premium assistance is treated as having been

the result on line 20.

made for each assistance eligible individual who paid 35% of the

COBRA premium. Do not include the assistance eligible

Your credit. If the amount entered on line 20 is less than zero,

individual's 35% of the premium in the amount entered on this

for example, “-115.00,” you have a credit because you

line.

overreported your federal employment taxes.

If you checked the box on line 1, include this amount on Form

For tax periods ending before January 1, 2014, enter any

941, line 11 (“Total deposits” line), for the quarter during which

COBRA premium assistance payments previously claimed on

you filed Form 941-X or Form 944, line 8 (“Total deposits” line),

Form 941 or 941-SS, line 12a, in column 2. For tax periods

for the year during which you filed Form 941-X. Do not make any

beginning after December 31, 2013, enter -0- in column 2,

changes to your record of federal tax liability reported on Form

unless you are correcting a COBRA premium assistance

941, line 14, or Schedule B (Form 941), if your Form 941-X is

payment previously reported on a Form 941-X. If you or the IRS

filed timely. The amounts reported on the record should reflect

previously corrected the amount reported, the amount entered in

your actual tax liability for the period.

column 2 should take into account all previous corrections.

If you checked the box on line 2, you are filing a claim for

refund or abatement of the amount shown.

Enter the difference between column 1 and 2 in column 3.

If your credit is less than $1, we will send a refund or apply it

Copy the amount in column 3 to column 4. However, to properly

only if you ask us in writing to do so.

show the amount as a credit or balance due item, enter a

positive number in column 3 as a negative number in column 4

Amount you owe. If the amount on line 20 is a positive

or a negative number in column 3 as a positive number in

number, you must pay the amount you owe by the time you file

column 4.

Form 941-X. You may not use any credit that you show on

another Form 941-X to pay the amount you owe, even if you filed

The COBRA premium assistance credit is treated as a

for the amount you owe and the credit at the same time.

credit on the first day of the return period (that is,

If you owe tax and are filing a timely Form 941-X, do not file

January 1, April 1, July 1, or October 1). However,

CAUTION

an amended Schedule B (Form 941) unless you were assessed

because the credit is now claimed on Form 941-X filed AFTER

an FTD penalty caused by an incorrect, incomplete, or missing

submission of the Form 941, an employer that reduces its

Schedule B (Form 941). Do not include the tax increase reported

required deposits in anticipation of the credit will receive a

on Form 941-X on any amended Schedule B (Form 941) you file.

system-generated notice reflecting a balance due and

associated penalties and interest, if applicable. The balance

If you owe tax and are filing a late Form 941-X, that is, after

due, including any related penalties and interest, resulting from

the due date for Form 941 for the quarter in which you

the reduction in deposits in anticipation of the credit will be

discovered the error, you must file an amended Schedule B

abated when the credit is applied. Such abatement will generally

(Form 941) with the Form 941-X. Otherwise, the IRS may assess

occur without any further action from the employer. Alternatively,

an “averaged” FTD penalty. The total tax reported on the “Total

to prevent triggering a system-generated balance due notice, the

liability for the quarter” line of Schedule B (Form 941), must

employer can make its deposits without a reduction in

match the corrected tax (Form 941, line 10, combined with any

anticipation of the COBRA premium assistance credit and follow

correction reported on Form 941-X, line 18) for the quarter, less

these instructions for claiming the COBRA premium assistance

any previous abatements and interest-free tax assessments.

credit.

-11-

Instructions for Form 941-X (Rev. 4-2015)

Instructions For Form 941-X - Adjusted Employer'S Quarterly Federal Tax Return Or Claim For Refund - 2017 Page 11

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