Form 8453-R
(Rev. January 2018)
Department of the Treasury
Internal Revenue Service
Electronic Filing Declaration for Form 8963
Go to www.irs.gov/Form8453R for the latest information.
OMB No. 1545-2253
For calendar year 20
Name of organization Employer identification number
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
9010 and is to pay this fee to the IRS on behalf of the controlled group. Each person that is a controlled group member at the end of the day on December 31,
2017, is jointly and severally liable for this fee. I further declare that each controlled group member 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 person who is a controlled group member at the end of the day on December 31, 2017, and
would qualify as a covered entity in 2018 if it were a single-person covered entity 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
Future Developments
For the latest information about developments related to Form
8453-R and its instructions, such as legislation enacted after they
were published, go to www.irs.gov/Form8453R.
Purpose of Form
Use Form 8453-R to authenticate the electronic filing of Form 8963,
Report of Health Insurance Provider Information.
Who Must File
If you file Form 8963 electronically in 2018, you must upload Form
8453-R with your report.
When To File
Form 8453-R must be filed with your electronically filed Form 8963.
How To File
Create a PDF file of the completed Form 8453-R and upload it with
Form 8963.
Declaration of Officer
An electronically transmitted report will not be considered complete
(and therefore not considered filed) unless Form 8453-R is signed
by an officer of the organization, scanned into a PDF file, and
transmitted with the report.
The officer's signature allows the IRS to disclose to the
transmitter:
• An acknowledgement that the IRS has accepted the
organization's electronically filed report, and
• The reason(s) for a delay in processing the report.
The declaration of officer must be signed and dated by:
• The president, vice president, treasurer, assistant treasurer, chief
accounting officer, or
• Any other officer of the organization, such as an officer of the
single-person covered entity or the designated entity, authorized to
sign the organization's report.
Paperwork Reduction Act Notice. We ask for the information on
this form to carry out the Internal Revenue laws of the United
States. You are required to give us the information. We need it to
ensure that you are complying with these laws and to allow us to
figure and collect the right amount of fees.
You are not required to provide the information requested on a
form that is subject to the Paperwork Reduction Act unless the form
displays a valid OMB control number. Books or records relating to a
form or its instructions must be retained as long as their contents
may become material in the administration of any Internal Revenue
law. The rules governing the confidentiality of this form are covered
in Internal Revenue Code section 6103.
The time needed to complete and file this form will vary depending
on individual circumstances. The estimated average time is:
Recordkeeping . . . . . . . . . . . . 1 hr., 12 min.
Learning about the law or the form . . . . . . . 12 min.
Preparing and sending the form . . . . . . . . 13 min.
Comments. If you have comments concerning the accuracy of
these time estimates or suggestions for making this form simpler,
we would be happy to hear from you. You can send us comments
from www.irs.gov/FormComments. Or you can write to the Internal
Revenue Service, Tax Forms and Publications Division, 1111
Constitution Ave. NW, IR-6526, Washington, DC 20224. Don't send
the form to this office.
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 60914Z
Form 8453-R (Rev. 1-2018)
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