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Форма 8928 Інструкції

Інструкції щодо форми 8928, повернення окремих видаткових оподаткування за главою 43 Кодексу внутрішнього доходів

Вересень 2016

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  • Форма 8928 - Повернення деяких видаткових податків під розділом 43 Кодексу внутрішнього доходів
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The form you are looking for begins on the next page of this file. Before viewing it,  
please see the important update information below.  
New Mailing Addresses  
Addresses for mailing certain forms have changed since the forms were last published. The new mailing  
addresses are shown below.  
Mailing address for Forms 706A, 706GS(D), 706GS(T), 706NA, 706QDT, 8612, 8725, 8831, 8842,  
8892, 8924, 8928:  
Department of the Treasury  
Internal Revenue Service Center  
Kansas City, MO 64999  
Mailing address for Forms 2678, 8716, 8822B, 8832, 8855:  
Taxpayers in the States Below  
Mail the Form to This Address  
Connecticut, Delaware, District of Columbia, Georgia, Illinois, Indiana,  
Kentucky, Maine, Maryland, Massachusetts, Michigan, New Hampshire,  
Department of the Treasury  
New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Internal Revenue Service Center  
South Carolina, Vermont, Virginia, West Virginia, Wisconsin  
Kansas City, MO 64999  
Alabama, Alaska, Arizona, Arkansas, California, Colorado, Florida, Hawaii,  
Idaho, Iowa, Kansas, Louisiana, Minnesota, Mississippi, Missouri,  
Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma,  
Oregon, South Dakota, Tennessee, Texas, Utah, Washington, Wyoming  
Department of the Treasury  
Internal Revenue Service Center  
Ogden, UT 84201  
This update supplements these forms’ instructions. Filers should rely on this update for  
the changes described, which will be incorporated into the next revision of the forms’  
instructions.  
Department of the Treasury  
Internal Revenue Service  
Instructions for Form 8928  
(Rev. September 2016)  
For use with Form 8928 (Rev. May 2016)  
Return of Certain Excise Taxes Under Chapter 43  
of the Internal Revenue Code  
Section references are to the Internal Revenue  
Code unless otherwise noted.  
3. Any employer liable for the tax  
under section 4980E for failure to make  
comparable Archer MSA contributions  
for all participating employees.  
4. Any employer liable for the tax  
under section 4980G for failure to make  
comparable HSA contributions for all  
participating employees.  
“timely mailing as timely filing/paying”  
rule for tax returns and payments.  
These private delivery services include  
only the following.  
Future Developments  
For the latest information about Form  
8928 and its instructions, such as  
legislation enacted after they were  
published, go to www.irs.gov/form8928.  
DHL Express (DHL): DHL Express  
9:00, DHL Express 10:30, DHL Express  
12:00, DHL Express Worldwide, DHL  
Express Envelope, DHL Import Express  
10:30, DHL Import Express 12:00, and  
DHL Import Express Worldwide.  
Federal Express (FedEx): FedEx First  
Overnight, FedEx Priority Overnight,  
FedEx Standard Overnight, FedEx  
2Day, FedEx International Next Flight  
Out, FedEx International Priority, FedEx  
International First, and FedEx  
General Instructions  
When To File  
For a failure under section 4980B or  
section 4980D, if the failure is by an  
employer or other person responsible  
for providing or administering benefits  
under the plan (such as an insurer or  
third-party administrator), file Form 8928  
on or before the due date for filing the  
person's federal income tax return.  
Purpose of Form  
File Form 8928 to report the tax due on  
the following failures by group health  
plans or employers.  
A failure to provide a level of  
coverage of the costs of pediatric  
vaccines (as defined in section 2612 of  
the Public Health Services Act) that is  
not below the coverage provided as of  
May 1, 1993.  
International Economy.  
United Parcel Service (UPS): UPS  
Next Day Air Early AM, UPS Next Day  
Air, UPS Next Day Air Saver, UPS 2nd  
Day Air, UPS 2nd Day Air A.M., UPS  
Worldwide Express Plus, and UPS  
Worldwide Express.  
If the failure under section 4980B or  
section 4980D is by a multiemployer or  
multiple employer plan, file Form 8928  
on or before the last day of the seventh  
month following the end of the plan  
year.  
For a failure under section 4980E or  
section 4980G, file Form 8928 on or  
before the 15th day of the 4th month  
following the calendar year in which the  
noncomparable contributions were  
made.  
A failure to satisfy continuation  
coverage requirements under section  
4980B.  
The private delivery service can tell  
you how to get written proof of the  
mailing date.  
A failure to meet portability, access,  
renewability, and market reform  
requirements under sections 9801,  
9802, 9803, 9811, 9812, 9813, and  
9815.  
Interest and Penalties  
Interest. Interest is charged on taxes  
not paid by the due date even if an  
extension of time to file is granted.  
Interest is also charged on penalties  
imposed from the due date, including  
extensions, to the date of payment for  
failure to file, negligence, fraud, gross  
valuation overstatements, and  
A failure to make comparable Archer  
medical savings account (MSA)  
contributions under section 4980E.  
A failure to make comparable health  
savings account (HSA) contributions  
under section 4980G.  
Extension. File Form 7004, Application  
for Automatic Extension of Time to File  
Certain Business Income Tax,  
Information, and Other Returns, to  
request an automatic extension of time  
to file Form 8928. You must file Form  
7004 on or before the regular due date  
of Form 8928. See the Instructions for  
Form 7004 for more information. Form  
7004 does not extend the time to pay  
excise taxes due under Form 8928.  
Who Must File  
substantial understatements of tax. The  
interest rate is determined under section  
6621.  
Penalty for late filing of return. If you  
do not file a return by the due date,  
Form 8928 must be filed by the  
following.  
1. Any employer, group health plan,  
plan administrator, or plan sponsor  
liable for the tax under section 4980B  
for failure to provide the required level of  
pediatric vaccine coverage or to offer  
continuation coverage to a qualified  
beneficiary.  
2. Any employer or group health  
plan liable for the tax under section  
4980D for failure to meet portability,  
access, renewability, and market reform  
requirements for group health plans  
under sections 9801, 9802, 9803, 9811,  
9812, 9813, and 9815.  
including extensions, you may have to  
pay a penalty of 5% of the unpaid tax for  
each month or part of a month the return  
is late, up to a maximum of 25% of the  
unpaid tax. The minimum penalty for a  
return that is more than 60 days late is  
the smaller of the tax due or $100. The  
penalty will not be imposed if you can  
show that the failure to file on time was  
due to reasonable cause. If you file late,  
you must attach a statement to Form  
8928 explaining the reasonable cause.  
Where To File  
Send Form 8928 to the  
following address.  
Department of the Treasury  
Internal Revenue Service  
Cincinnati, OH 45999-0009  
Private delivery services. You can  
use certain private delivery services  
designated by the IRS to meet the  
Sep 01, 2016  
Cat. No. 52470C  
ended March 31, 2016, should be  
shown as 03/31/2016.  
Penalty for late payment of tax. If  
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; or  
you do not pay the tax when due, you  
1
2
may have to pay a penalty of of 1% of  
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.  
the unpaid tax for each month or part of  
a month the tax is not paid, up to a  
maximum of 25% of the unpaid tax. The  
penalty will not be imposed if you can  
show that the failure to pay on time was  
due to reasonable cause.  
Interest and penalties for late filing  
and late payment will be billed  
separately after the return is filed.  
If the plan number is not  
provided, this will cause a delay  
!
Claim for Refund or Credit/  
Amended Return  
CAUTION  
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.  
File an amended Form 8928 for any of  
the following.  
To claim a refund of overpaid taxes  
reportable on Form 8928.  
To receive a credit for overpaid taxes.  
To report additional taxes due within  
the same tax year of the filer if those  
taxes have the same due date as those  
previously reported.  
File an amended return by writing  
“Amended Return” at the top of Form  
8928 and completing the appropriate  
part.  
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.  
If you file an amended return to claim  
a refund or credit, the claim must state  
in detail the reasons for claiming the  
refund. In order for the IRS to promptly  
consider your claim, you must explain  
why you are filing the claim and provide  
the appropriate supporting evidence.  
See Regulations section 301.6402-2 for  
more details.  
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.  
You can apply for a PTIN online or by  
filing Form W-12, IRS Paid Preparer Tax  
Identification Number (PTIN)  
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.  
Application and Renewal. For more  
information about applying for a PTIN  
online, visit the IRS website at  
Part I. Tax on Failure To  
Satisfy Continuation  
Coverage Requirements  
Under Section 4980B  
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.  
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  
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  
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  
-2-  
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.  
employed fewer than 20 employees on  
a typical business day.  
Any governmental plan under section  
414(d).  
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.  
Any church plan under section  
414(e).  
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.  
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  
6 months after the last day of the  
maximum continuation coverage period  
under the qualifying event that led to the  
failure.  
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.  
Write “Summary Form” at the top to  
indicate that this is a summary form and  
attach all copies to it.  
The noncompliance period may  
include portions of more than 1  
plan year (in the case of an  
TIP  
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  
million for all plans for failures due to  
reasonable cause and not to willful  
neglect. For those entities, do not enter  
more than $2 million on this line for such  
failures for all plans even if the  
You may report all failures on  
employee benefit plan) or 1 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.  
the same form if the failures  
occurred during the same tax  
TIP  
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).  
aggregate excise tax owed for all  
failures under Part I, Section A, is more  
than $2 million.  
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.  
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  
6 months after the last day of the  
maximum continuation coverage period  
under the qualifying event that led to the  
failure.  
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.  
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  
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,  
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  
Section B, on line 15 of your summary  
employers maintaining the plan normally  
-3-  
form. See the discussion under Part I  
earlier.  
50 employees on business days during  
the preceding calendar year, and who  
employs at least 2 employees on the  
tax liability was sent from the IRS and  
the failure or failures continued during  
the examination period. The minimum  
first day of the current plan year. Special excise tax under Part II, Section A, is  
Part II. Tax on Failure To  
Meet Portability, Access,  
and Renewability  
rules apply to employers not in  
existence in the preceding year. See  
section 4980D(d)(2)(B).  
$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 Under  
Section 4980D  
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.  
Complete a separate Part II, Section A,  
lines 17 through 23, for each failure to  
meet portability, access, and  
requirements for a church plan, enter  
“-0-” on this line and go to line 23.  
renewability requirements that occurred  
during the reporting period that was due  
to reasonable cause and not to willful  
neglect. If multiple such failures  
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  
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.  
The noncompliance period may  
include portions of more than 1  
plan year (in the case of an  
TIP  
employee benefit plan) or 1 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.  
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.  
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  
Line 21. No tax is due for any failure  
under Part II, Section A, if it is  
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.  
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.  
“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.  
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).  
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  
Part III. Tax on Failure To  
Make Comparable Archer  
MSA Contributions Under  
Section 4980E  
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  
An employer is liable for tax under  
section 4980E if he fails to make  
comparable contributions to the Archer  
MSAs of all comparable participating  
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  
-4-  
employees for each coverage period  
during the calendar year.  
under this part, to the extent that  
be retained as long as their contents  
may become material in the  
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.  
administration of any Internal Revenue  
law. Generally, tax returns and return  
information are confidential, as required  
by section 6103.  
“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.  
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.  
The time needed to complete and file  
this form will vary depending on  
individual circumstances. The estimated  
average time is:  
“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.  
Part V. Tax Due  
Recordkeeping. . .  
12 hr., 40 min.  
Make your check or money  
order payable to “United States  
Treasury” for the full amount  
Learning about  
the law or the  
form . . . . . . . . . . .  
4 hr., 0 min.  
due. Attach the payment to your return.  
Write your name, identifying number,  
plan number, and “Form 8928,  
Part(s)____” on your payment.  
To determine whether contributions  
are comparable, see Regulations  
sections 54.4980G-1 through  
54.4980G-7.  
Preparing and  
sending the form  
to the IRS . . . . . . .  
6 hr., 47 min.  
Line 35. Enter the aggregate amount  
contributed to employees' Archer MSAs  
for tax years ending with or within the  
calendar year.  
File at the address shown under Where  
To File, earlier.  
Comments and suggestions. We  
welcome your comments about this  
publication and your suggestions for  
future editions. You can send us  
comments from www.irs.gov/  
Privacy Act and Paperwork Reduc-  
tion Act Notice. We ask for the  
Waiver of excise tax. The Secretary  
may waive part or all of the excise tax  
under this part, to the extent that  
information on this form to carry out the  
Internal Revenue laws of the United  
States. Taxpayers subject to the  
formspubs. Click on "More Information"  
and then on "Give us feedback." Or you  
can write to:  
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.  
provisions of sections 4980B, 4980D,  
4980E, and 4980G are required to  
provide the information requested on  
this form. Section 6109 requires you to  
provide your identifying number. If you  
fail to provide this information in a timely  
manner, you may be liable for penalties.  
Routine uses of this information include  
giving it to the Department of Justice for  
civil and criminal litigation, to other  
federal agencies as authorized by law,  
and to cities, states, the District of  
Columbia, and U.S. commonwealths  
and possessions for use in  
Internal Revenue Service  
Tax Forms and Publications  
1111 Constitution Ave. NW  
IR-6526  
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.  
Washington, DC 20224  
Part IV. Tax on Failure To  
Make Comparable HSA  
Contributions Under  
Section 4980G  
We respond to many letters by  
telephone. Therefore, it would be helpful  
if you would include your daytime phone  
number, including the area code, in your  
correspondence. Although we cannot  
respond individually to each comment  
received, we do appreciate your  
feedback and will consider your  
comments as we revise our tax  
products.  
administering their tax laws. We may  
also disclose this information to other  
countries under a tax treaty, to federal  
and state agencies to enforce federal  
nontax criminal laws, or to federal law  
enforcement and intelligence agencies  
to combat terrorism.  
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.  
Ordering forms and publications.  
download forms and publications.  
Otherwise, you can go to www.irs.gov/  
orderforms to order forms.  
Line 37. Enter the aggregate amount  
contributed to employees' HSAs for tax  
years ending with or within the calendar  
year.  
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  
Waiver of excise tax. The Secretary  
may waive part or all of the excise tax  
relating to a form or its instructions must  
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