Form 14199 (Rev. 1-2011)
Form 14199
(January 2011)
Catalog Number 57048S
COBRA Recapture Statement
Department of the Treasury — Internal Revenue Service
Complete the following information
Taxpayer Name Social Security Number
Daytime telephone number
(including area code)
( )
Complete the following information
(Print Name)
, under penalties of perjury, certify that I did not meet the
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
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