Fillable COBRA Recapture Statement Form 14199 Jan-2011

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COBRA Recapture Statement Form 14199 Jan-2011

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The COBRA Recapture Statement Form 14199 Jan-2011 form is 1 page long and contains:

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Country of origin: US
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The Internal Revenue Service (IRS) is a government agency responsible for collecting taxes and administering the federal statutory tax laws of the United States. The IRS provide tax assistance to taxpayers and pursue and resolve fraudulent tax filings.

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Form 14199 (Rev. 1-2011)
Form 14199
(January 2011)
Catalog Number 57048S
COBRA Recapture Statement
Department of the Treasury — Internal Revenue Service
www.irs.gov
Complete the following information
Taxpayer Name Social Security Number
Daytime telephone number
(including area code)
( )
-
Complete the following information
I,
(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.
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COBRA Recapture Statement Form 14199 Jan-2011

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Completed 18 May 2019

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