Fillable F8928 Accessible Form 8928 (Rev. May 2016)

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F8928 Accessible Form 8928 (Rev. May 2016)

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the important update information below.
New Mailing Addresses
Addresses for mailing certain forms have changed since the forms were last published. The new mailing
addresses are shown below.
Mailing address for Forms 706‐A, 706‐GS(D), 706‐GS(T), 706‐NA, 706‐QDT, 8612, 8725, 8831, 8842,
8892, 8924, 8928:
Department of the Treasury
Internal Revenue Service Center
Kansas City, MO 64999
Mailing address for Forms 2678, 8716, 8822-B, 8832, 8855:
Taxpayers in the States Below Mail the Form to This Address
Connecticut, Delaware, District of Columbia, Georgia,
Illinois, Indiana,Kentucky, Maine, Maryland,
Massachusetts, Michigan, New Hampshire, New Jersey,
New York, North Carolina, Ohio, Pennsylvania, Rhode
Island, South Carolina, Vermont, Virginia, West Virginia,
Wisconsin
Department of the Treasury
Internal Revenue Service Center
Kansas City, MO 64999
Alabama, Alaska, Arizona, Arkansas, California,
Colorado, Florida, Hawaii, Idaho, Iowa, Kansas,
Louisiana, Minnesota, Mississippi, Missouri, Montana,
Nebraska, Nevada, New Mexico, North Dakota,
Oklahoma, Oregon, South Dakota, Tennessee, Texas,
Utah, Washington, Wyoming
Department of the Treasury
Internal Revenue Service Center
Ogden, UT 84201
This update supplements these forms’ instructions. Filers should rely on this update for the changes described,
which will be incorporated into the next revision of the forms’ instructions.
Form 8928
(Rev. May 2016)
Department of the Treasury
Internal Revenue Service
Return of Certain Excise Taxes Under
Chapter 43 of the Internal Revenue Code
(Under sections 4980B, 4980D, 4980E, and 4980G)
▶
Information about Form 8928 and its separate instructions is at www.irs.gov/form8928.
OMB No. 1545-2146
Filer's tax year beginning
,
and ending
,
A Name of filer (see instructions)
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
B Filer’s employer identification
number (EIN)
C Name of plan
D Name and address of plan sponsor
E Plan sponsor’s EIN
F Plan year ending (MM/DD/YYYY)
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% (0.10) . . . . . . . . . . . . . . . . . . . . . .
9
10 Amount from section 4980B(c)(4) . . . . . . . . . . . . . . . . . . . . 10
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 Add lines 11 and 15 . . . . . . . . . . . . . . . . . . . . . . . .
▶
126 16
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 37742T
Form 8928 (Rev. 5-2016)
Form 8928 (Rev. 5-2016)
Page
2
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 . . . . . . . 17
18 Enter the number of individuals to whom the failure applies . . . 18
19 Multiply line 17 by line 18 . . . . . . . . . . . . . . . 19
20 Multiply line 19 by $100 . . . . . . . . . . . . . . . . . . . . . . . 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 . . . . . . .
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- . . . . . . . . .
22
23 Enter the smaller of line 20 or line 22 . . . . . . . . . . . . . . . . . . . 23
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 . .
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. . .
25
26 Multiply line 25 by 10% (0.10) . . . . . . . . . . . . . . . . . . . . . 26
27 Amount from section 4980D(c)(3) . . . . . . . . . . . . . . . . . . . . 27
28 Enter the smallest of lines 24, 26, or 27 . . . . . . . . . . . . . . . . . . 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 . . . . . . . 29
30 Enter the number of individuals to whom the failure applies . . . 30
31 Multiply line 29 by line 30 . . . . . . . . . . . . . . . 31
32 Multiply line 31 by $100 . . . . . . . . . . . . . . . . . . . . . . . 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 . .
33
Section C – Total Tax Due Under Section 4980D
34 Add lines 28 and 33 . . . . . . . . . . . . . . . . . . . . . . . .
▶
127 34
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 . . . . 35
36 Total tax due under section 4980E. Multiply line 35 by 35% (0.35) . . . . . . . . .
▶
128 36
Part IV Tax on Failure To Make Comparable HSA Contributions Under Section 4980G
37 Aggregate amount contributed to HSAs of employees within calendar year . . . . . . 37
38 Total tax due under section 4980G. Multiply line 37 by 35% (0.35) . . . . . . . . .
▶
137 38
Part V Tax Due or Overpayment
39 Add lines 16, 34, 36, and 38 . . . . . . . . . . . . . . . . . . . . . . 39
40 Enter amount of tax paid with Form 7004 . . . . . . . . . . . . . . . . . 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 . . . . .
41
42 Overpayment. Subtract line 39 from line 40 . . . . . . . . . . . . . . . . 42
Sign
Here
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
has any knowledge.
▲
Your signature
▲
Telephone number
▲
Date
Paid
Preparer
Use Only
Print/Type preparer's name Preparer's signature Date
Check if
self-employed
PTIN
Firm's name
▶
Firm's address
▶
Firm's EIN
▶
Phone no.
Form 8928 (Rev. 5-2016)
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F8928 Accessible Form 8928 (Rev. May 2016)

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Completed 30 June 2020

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