Filer tax year.
Enter the tax year of the employer, entity, or individual on whom the tax is imposed by using the plan year beginning
and ending dates entered in Part I of Form 5500 or by using the tax year of the business return filed, if applicable.
Item A. Name and address of filer.
Enter the name and address of the employer, individual, or other entity who is liable for the tax.
Include the suite, room, or other unit numbers after the street number. If the post office does not deliver mail to
the street address and you have a P.O. box, show the box number instead of the street address.
If the entity has a foreign address, enter the information in the following order: city or town, province or state,
and country. Follow the country's practice for entering the postal code. Do not abbreviate the country name.
Item C. Name of plan.
Enter the formal name of the plan, name of the plan sponsor, or name of the insurance company or financial institution
of the direct filing entity (DFE). In the case of a group insurance arrangement (GIA), enter the name of the trust or other
entity that holds the insurance contract. In the case of a master trust investment account (MTIA), enter the name of the sponsoring
employers.
If the plan covers only the employees of one employer, enter the employer's name or enough information to identify
the plan. This should be the same name indicated on the Form 5500 series return/report if that form is required to be filed
for the plan.
Item D. Name and address of plan sponsor.
The term “
plan sponsor” means:
-
The employer, for a group health plan established or maintained by a single employer;
-
The employee organization, in the case of a plan of an employee organization;
-
The association, committee, joint board of trustees, or other similar group of representatives of the parties who establish
or maintain the plan, if the group health plan is established or maintained jointly by one or more employers and one or more
employee organizations, or by two or more employers.
Include the suite, room, or other unit numbers after the street number. If the post office does not deliver mail to
the street address and you have a P.O. box, show the box number instead of the street address.
If the plan sponsor has a foreign address, enter the information in the following order: city or town, province or
state, and country. Follow the country's practice for entering the postal code. Do not abbreviate the country name.
Item E. Plan sponsor's EIN.
Enter the nine-digit employer identification number (EIN) assigned to the plan sponsor. This should be the same number
used to file the Form 5500 series return/report.
Item F. Plan year ending.
“
Plan year” is defined in Regulations section 54.9801-2. Enter eight digits in month/date/year order. This number assists the IRS in
properly identifying the plan and time period for which the Form 8928 is being filed. For example, a plan year ended March
31, 2010, should be shown as 03/31/2010.
Item G. Plan number.
Enter the three-digit number that the employer or plan administrator assigned to the plan. This three-digit number
is used with the EIN entered on line B and is used by the IRS, the Department of Labor, and the Pension Benefit Guaranty Corporation
as a unique 12-digit number to identify the plan.
If the plan number is not provided, this will cause a delay in processing your return.
Filer's signature.
To reduce the possibility of correspondence and penalties, please sign and date the form. Also enter a daytime phone
number where you can be reached.
Paid preparer's signature.
Anyone who prepares your return and does not charge you should not sign the return. For example, a regular full-time
employee or your business partner who prepares the return should not sign.
Generally, anyone who is paid to prepare the return must sign the return in the space provided and fill in the
Paid Preparer Use Only area. See section 7701(a)(36)(B) for exceptions.
In addition to signing and completing the required information, the paid preparer must give a copy of the completed
return to the taxpayer.
Note.
A paid preparer may sign original or amended returns by rubber stamp, mechanical device, or computer software program.
Part I. Tax on Failure To Satisfy Continuation Coverage Requirements Under Section 4980B
Complete a separate Part I, Section A, lines 1 through 6 for each qualifying event for which one or more failures to satisfy
continuation coverage requirements occurred during the reporting period as a result of failures due to reasonable cause and
not to willful neglect. If multiple qualifying events occurred with different noncompliance periods, complete lines 1 through
6 on a separate Part I for each qualifying event. Then complete a “summary” Form 8928 with items A through G and enter the total amount of the excise tax on line 7 of that summary form and complete
lines 8 through 11 for all qualifying events as a result of failures due to reasonable cause and not to willful neglect.
Complete a separate Part I, lines 12 through 14, for each qualifying event for which one or more failures to satisfy continuation
coverage requirements occurred during the reporting period as a result of failures due to willful neglect or otherwise not
due to reasonable cause. If multiple qualifying events occurred with different noncompliance periods, complete lines 12 through
14 on a separate Part I for each qualifying event. Then complete a “summary” Form 8928 with items A through G and enter the total amount of the excise tax on line 15 of that summary form for all failures
that were due to willful neglect or otherwise not due to reasonable cause.
Write “Summary Form” at the top to indicate that this is a summary form and attach all copies to it.
You may report all failures on the same form if the failures occurred during the same tax year.
For purposes of Part I, a qualifying event is any of the following.
-
Death of the covered employee.
-
Termination or reduction of hours of the covered employee's employment (other than for employee gross misconduct).
-
Divorce or legal separation of the covered employee from the employee's spouse.
-
Covered employee becoming entitled to Medicare benefits.
-
Dependent child of the covered employee ceasing to be a covered child under the terms of the plan.
-
Bankruptcy of the employer from whose employment the covered employee retired.
Waiver of excise tax.
The Secretary may waive part or all of the excise tax under Part I, to the extent that payment of the tax would be
excessive relative to the failure involved. This only applies to failures due to reasonable cause and not due to willful neglect.
Note.
The tax under Part I will not apply to the following.
-
Any failure of a group health plan if the qualifying event occurred during the calendar year immediately following a calendar
year during which all employers maintaining the plan normally employed fewer than 20 employees on a typical business day.
-
Any governmental plan under section 414(d).
-
Any church plan under section 414(e).
Section A—Failures Due to Reasonable Cause and Not to Willful Neglect
If the failure or failures as a result of a particular qualifying event were due to reasonable cause and not to willful neglect,
complete Part I, Section A, lines 1 through 11.
Line 1.
Calculate the total number of days of noncompliance within the reporting period beginning on the date the failure
first occurred and ending on the earlier of the date the failure is corrected or, at the latest, a date that is six months
after the last day of the maximum continuation coverage period under the qualifying event that led to the failure.
The noncompliance period may include portions of more than one plan year (in the case of an employee benefit plan) or one
tax year (in the case of an employer or third-party administrator). In that case, only the portion of the noncompliance period
falling within that plan year or tax year would be used to calculate the excise tax due for that year.
Line 4.
No tax is due for any failure under Part I, Section A if it is established to the satisfaction of the Secretary of
the Treasury that no one liable for the tax knew, or exercising reasonable diligence would have known, that the failure occurred.
Additionally, no tax is due if the failure under Part I, Section A was due to reasonable cause and not due to willful neglect
and the failure was corrected during the 30-day period beginning on the 1st date anyone liable for the tax knew, or exercising
reasonable diligence should have known, that the failure existed.
For this purpose, a failure is treated as corrected if the failure is retroactively undone to the extent possible
and the qualified beneficiary to whom the failure relates is placed in a financial position which is as good as such beneficiary
would have been in had the failure not occurred.
Line 5.
The minimum excise tax under Part I, Section A is $2,500 for each qualified beneficiary for whom one or more failures
occurred if the failure or failures were not corrected before the date a notice of examination of income tax liability was
sent from the IRS and the failure or failures continued during the examination period. The minimum excise tax under Part I,
Section A is $15,000 if the failure or failures are determined to be more than
de minimis.
Line 7.
If you had more than one qualifying event during the reporting period, complete lines 1 through 6 in a separate Part
I, Section A for each qualifying event and enter the total from line 6 from all copies of Part I, Section A on line 7 of your
summary form. See the discussion under Part I earlier.
Line 8.
For a single employer plan, enter on line 8 the aggregate amount paid or incurred during the preceding tax year by
the employer (or a predecessor) for its group health plan. For a multiemployer plan, enter on this line the amount paid or
incurred during the current tax year to provide medical care, directly or through insurance or reimbursement.
Line 11.
The maximum excise tax payable during a tax year by third-party administrators, HMOs, and insurance companies under
Part I, Section A is $2,000,000 for all plans for failures due to reasonable cause not to willful neglect. For those entities,
do not enter more than $2,000,000 on this line for such failures for all plans even if the aggregate excise tax owed for all
failures under Part I, Section A is more than $2,000,000.
Section B—Failures Due to Willful Neglect or Otherwise Not Due to Reasonable Cause
If the failure or failures as a result of a particular qualifying event were due to willful neglect or otherwise not due to
reasonable cause, complete Part I, Section B, lines 12 through 15.
Line 12.
Calculate the total number of days of noncompliance within the reporting period beginning on the date the failure
first occurred and ending on the earlier of the date the failure is corrected or, at the latest, a date that is six months
after the last day of the maximum continuation coverage period under the qualifying event that led to the failure.
Line 15.
If you had more than one qualifying event during the reporting period, complete lines 12 through 14 in a separate
Part I, Section B for each qualifying event and enter the total from line 14 from all copies of Part I, Section B on line
15 of your summary form. See the discussion under Part I earlier.
Part II. Tax on Failure To Meet Portability, Access, and Renewability Requirements Under Section 4980D
Complete a separate Part II, Section A, lines 17 through 23 for each failure to meet portability, access, and renewability
requirements that occurred during the reporting period that was due to reasonable cause and not to willful neglect. If multiple
such failures occurred with different noncompliance periods, complete lines 17 through 23 in a separate Part I, Section A
for each failure. Then complete a “summary” Form 8928 with items A through G and enter the total amount of the excise tax on line 24 of that summary form and complete
lines 25 through 28 for all failures due to reasonable cause and not to willful neglect.
Complete a separate Part II, Section B, lines 29 through 33, for each failure to meet portability, access, and renewability
requirements that occurred during the reporting period that was due to willful neglect or otherwise not due to reasonable
cause. If multiple failures occurred with different noncompliance periods, complete lines 29 through 32 on a separate Part
II, Section B for each failure. Then complete a “summary” Form 8928 with items A through G and enter the total amount of the excise tax on line 33 of that summary form for all such
failures.
Write “Summary Form” at the top to indicate that this is a summary form and attach all copies to it.
Waiver of excise tax.
The Secretary may waive part or all of the excise tax under Part II, to the extent that payment of the tax would be
excessive relative to the failure involved. This only applies to failures due to reasonable cause and not due to willful neglect.
Exception for certain insured small employer plans.
If you are a small employer who provides health insurance coverage solely through a contract with a health insurance
issuer, you will not be liable for the excise tax under Part II for any failure (other than a failure under section 9811)
that is solely the result of the health insurance coverage offered by the issuer.
“
Small employer” is generally defined as an employer who employed an average of at least 2 but not more than 50 employees on business days
during the preceding calendar year, and who employs at least 2 employees on the first day of the current plan year. Special
rules apply to employers not in existence in the preceding year. See section 4980D(d)(2)(B).
Section A—Failures Due to Reasonable Cause and Not to Willful Neglect
If the failure or failures were due to reasonable cause and not to willful neglect, complete Part II, Section A, lines 17
through 28.
Line 17.
Calculate the total number of days of noncompliance within the reporting period beginning on the date the failure
first occurred and ending on the date the failure is corrected.
The noncompliance period may include portions of more than one plan year (in the case of an employee benefit plan) or one
tax year (in the case of an employer or third-party administrator). In that case, only the portion of the noncompliance period
falling within that plan year or tax year would be used to calculate the excise tax due for that year.
Line 21.
No tax is due for any failure under Part II, Section A if it is established to the satisfaction of the Secretary of
the Treasury that no one liable for the tax knew, or exercising reasonable diligence would have known, that the failure occurred.
Additionally, no tax is due if the failure under Part II, Section A was due to reasonable cause and not due to willful neglect
and the failure was corrected during the 30-day period beginning on the first date anyone liable for the tax knew, or exercising
reasonable diligence would have known, that the failure existed.
For this purpose, a failure is treated as corrected if the failure is retroactively undone to the extent possible
and the person to whom the failure relates is placed in a financial position which is as good as such person would have been
in had the failure not occurred.
In the case of a church plan, the failure must be corrected before the close of the correction period, as defined
under section 414(e)(4)(C).
Line 22.
The minimum excise tax under Part II, Section A is $2,500 for each qualified beneficiary for whom one or more failures
occurred if the failure or failures were not corrected before the date a notice of examination of income tax liability was
sent from the IRS and the failure or failures continued during the examination period. The minimum excise tax under Part II,
Section A, is $15,000 if the failure or failures are determined to be more than
de minimis.
Exception for church plans.
The $2,500 (or $15,000 if applicable) minimum excise tax does not apply to a church plan, as defined in section 414(e). If
your plan meets the requirements for a church plan, enter “-0-” on this line and go to line 23.
Line 24.
If you had more than one failure during the reporting period, complete lines 17 through 23 in a separate Part II,
Section A for each failure and enter the total from line 23 from all copies of Part II, Section A on line 24 of your summary
form. See the discussion under Part I earlier.
Line 25.
For a single employer plan, enter on this line the aggregate amount paid or incurred during the preceding tax year
by the employer (or a predecessor) for its group health plan. For a multiemployer plan, enter on this line the amount paid
or incurred during the current tax year to provide medical care, directly or through insurance or reimbursement.
Section B—Failure Due to Willful Neglect or Otherwise Not Due to Reasonable Cause
If the failure or failures were due to willful neglect or otherwise not due to reasonable cause, complete Part II, Section
B, lines 29 through 33.
Line 29.
Calculate the total number of days of noncompliance within the reporting period beginning on the date the failure
first occurred and ending on the date the failure is corrected.
Line 33.
If you had more than one failure during the reporting period, complete lines 29 through 32 in a separate Part II,
Section B for each qualifying event and enter the total from line 32 from all copies of Part II, Section B on line 33 of your
summary form. See the discussion under Part I earlier.
Part III. Tax on Failure To Make Comparable Archer MSA Contributions Under Section 4980E
An employer is liable for tax under section 4980E if he fails to make comparable contributions to the Archer MSAs of all comparable
participating employees for each coverage period during the calendar year.
“Comparable contributions” are contributions which are the same amount or which are the same percentage of the annual deductible limit under the high
deductible health plan covering the employees.
“Comparable participating employees” are employees who are eligible individuals covered under any high deductible health plan of the employer, and who have the
same category of coverage.
To determine whether contributions are comparable, see Regulations sections 54.4980G-1 through 54.4980G-7.
Line 35.
Enter the aggregate amount contributed to employees' Archer MSAs for tax years ending with or within the calendar
year.
Waiver of excise tax.
The Secretary may waive part or all of the excise tax under this part, to the extent that payment of the tax would
be excessive relative to the failure involved. This only applies to failures due to reasonable cause and not to willful neglect.
Controlled group.
For purposes of this part, all persons treated as a single employer under section 414(b), (c), (m), or (o) will be
treated as one employer.
Part IV. Tax on Failure To Make Comparable HSA Contributions Under Section 4980G
An employer is liable for tax under section 4980G if he fails to make comparable contributions to the HSAs of all comparable
participating employees for each coverage period during the calendar year.
Line 37.
Enter the aggregate amount contributed to employees' health savings accounts for tax years ending with or within the
calendar year.
Waiver of excise tax.
The Secretary may waive part or all of the excise tax under this part, to the extent that payment of the tax would
be excessive relative to the failure involved. This only applies to failures due to reasonable cause and not to willful neglect.
Controlled group.
For purposes of this part, all persons treated as a single employer under section 414(b), (c), (m), or (o) will be
treated as one employer.
Make your check or money order payable to the “United States Treasury” for the full amount due. Attach the payment to your return. Write your name, identifying number, plan number, and “Form 8928, Part(s)____” on your payment.
File at the address shown under Where To File, earlier.
