Specific Instructions

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, state or province, 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:
  1. The employer, for a group health plan established or maintained by a single employer;

  2. The employee organization, in the case of a plan of an employee organization;

  3. 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, state or province, 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, 2013, should be shown as 03/31/2013.

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 Use Only.   A paid preparer must sign Form 8928 and provide the information in the Paid Preparer Use Only section at the end of the form if the preparer was paid to prepare the form and is not an employee of the filing entity. The preparer must give you a copy of the form in addition to the copy to be filed with the IRS.

  If you are a paid preparer, enter your Preparer Tax Identification Number (PTIN) in the space provided. Include your complete address. If you work for a firm, you also must enter the firm’s name and the EIN of the firm. However, you cannot use the PTIN of the tax preparation firm in place of your PTIN.

  You can apply for a PTIN online or by filing Form W-12, IRS Paid Preparer Tax Identification Number (PTIN) Application and Renewal. For more information about applying for a PTIN online, visit the IRS website at www.irs.gov/taxpros.

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.

Part V. Tax Due

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.


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