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Department of the Treasury
Instructions for Form 8928 Internal Revenue Service

(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 3. Any employer liable for the tax “timely mailing as timely filing/paying”
Code unless otherwise noted. under section 4980E for failure to make rule for tax returns and payments.
comparable Archer MSA contributions These private delivery services include
Future Developments for all participating employees. only the following.
For the latest information about Form 4. Any employer liable for the tax DHL Express (DHL): DHL Express
8928 and its instructions, such as under section 4980G for failure to make 9:00, DHL Express 10:30, DHL Express
legislation enacted after they were comparable HSA contributions for all 12:00, DHL Express Worldwide, DHL
published, go to www.irs.gov/form8928. participating employees. Express Envelope, DHL Import Express
10:30, DHL Import Express 12:00, and
General Instructions When To File DHL Import Express Worldwide.
Federal Express (FedEx): FedEx First
For a failure under section 4980B or
Overnight, FedEx Priority Overnight,
Purpose of Form section 4980D, if the failure is by an
FedEx Standard Overnight, FedEx
File Form 8928 to report the tax due on employer or other person responsible
2Day, FedEx International Next Flight
the following failures by group health for providing or administering benefits
Out, FedEx International Priority, FedEx
plans or employers. under the plan (such as an insurer or
International First, and FedEx
A failure to provide a level of third-party administrator), file Form 8928
International Economy.
coverage of the costs of pediatric on or before the due date for filing the
United Parcel Service (UPS): UPS
vaccines (as defined in section 2612 of person's federal income tax return.
Next Day Air Early AM, UPS Next Day
the Public Health Services Act) that is
If the failure under section 4980B or Air, UPS Next Day Air Saver, UPS 2nd
not below the coverage provided as of
section 4980D is by a multiemployer or Day Air, UPS 2nd Day Air A.M., UPS
May 1, 1993.
multiple employer plan, file Form 8928 Worldwide Express Plus, and UPS
A failure to satisfy continuation
on or before the last day of the seventh Worldwide Express.
coverage requirements under section
month following the end of the plan
4980B. The private delivery service can tell
year.
A failure to meet portability, access, you how to get written proof of the
renewability, and market reform For a failure under section 4980E or mailing date.
requirements under sections 9801, section 4980G, file Form 8928 on or
9802, 9803, 9811, 9812, 9813, and before the 15th day of the 4th month Interest and Penalties
9815. following the calendar year in which the Interest. Interest is charged on taxes
A failure to make comparable Archer noncomparable contributions were not paid by the due date even if an
medical savings account (MSA) made. extension of time to file is granted.
contributions under section 4980E. Extension. File Form 7004, Application Interest is also charged on penalties
A failure to make comparable health for Automatic Extension of Time to File imposed from the due date, including
savings account (HSA) contributions Certain Business Income Tax, extensions, to the date of payment for
under section 4980G. Information, and Other Returns, to failure to file, negligence, fraud, gross
request an automatic extension of time valuation overstatements, and
Who Must File to file Form 8928. You must file Form substantial understatements of tax. The
Form 8928 must be filed by the 7004 on or before the regular due date interest rate is determined under section
following. of Form 8928. See the Instructions for 6621.
1. Any employer, group health plan, Form 7004 for more information. Form Penalty for late filing of return. If you
plan administrator, or plan sponsor 7004 does not extend the time to pay do not file a return by the due date,
liable for the tax under section 4980B excise taxes due under Form 8928. including extensions, you may have to
for failure to provide the required level of pay a penalty of 5% of the unpaid tax for
pediatric vaccine coverage or to offer Where To File each month or part of a month the return
continuation coverage to a qualified is late, up to a maximum of 25% of the
Send Form 8928 to the
beneficiary. unpaid tax. The minimum penalty for a
following address.
2. Any employer or group health return that is more than 60 days late is
plan liable for the tax under section Department of the Treasury the smaller of the tax due or $100. The
4980D for failure to meet portability, Internal Revenue Service penalty will not be imposed if you can
access, renewability, and market reform Cincinnati, OH 45999-0009 show that the failure to file on time was
requirements for group health plans due to reasonable cause. If you file late,
under sections 9801, 9802, 9803, 9811, you must attach a statement to Form
9812, 9813, and 9815. Private delivery services. You can 8928 explaining the reasonable cause.
use certain private delivery services
designated by the IRS to meet the

Sep 01, 2016 Cat. No. 52470C

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Penalty for late payment of tax. If Item C. Name of plan. Enter the ended March 31, 2016, should be
you do not pay the tax when due, you formal name of the plan, name of the shown as 03/31/2016.
may have to pay a penalty of of 1% of 12 plan sponsor, or name of the insurance Item G. Plan number. Enter the
the unpaid tax for each month or part of company or financial institution of the three-digit number that the employer or
a month the tax is not paid, up to a direct filing entity (DFE). In the case of a plan administrator assigned to the plan.
maximum of 25% of the unpaid tax. The group insurance arrangement (GIA), This three-digit number is used with the
penalty will not be imposed if you can enter the name of the trust or other EIN entered on line B and is used by the
show that the failure to pay on time was entity that holds the insurance contract. IRS, the Department of Labor, and the
due to reasonable cause. In the case of a master trust investment Pension Benefit Guaranty Corporation
Interest and penalties for late filing account (MTIA), enter the name of the as a unique 12-digit number to identify
and late payment will be billed sponsoring employers. the plan.
separately after the return is filed. If the plan covers only the employees If the plan number is not
of one employer, enter the employer's provided, this will cause a delay
Claim for Refund or Credit/ name or enough information to identify CAUTION! in processing your return.
Amended Return the plan. This should be the same name
indicated on the Form 5500 series Filer's signature. To reduce the
File an amended Form 8928 for any of return/report if that form is required to be possibility of correspondence and
the following. filed for the plan. penalties, please sign and date the
To claim a refund of overpaid taxes
reportable on Form 8928. Item D. Name and address of plan form. Also enter a daytime phone
To receive a credit for overpaid taxes. sponsor. The term “plan sponsor” number where you can be reached.
To report additional taxes due within means: Paid Preparer Use Only. A paid
the same tax year of the filer if those 1. The employer, for a group health preparer must sign Form 8928 and
taxes have the same due date as those plan established or maintained by a provide the information in the Paid
previously reported. single employer; Preparer Use Only section at the end of
File an amended return by writing 2. The employee organization, in the form if the preparer was paid to
“Amended Return” at the top of Form the case of a plan of an employee prepare the form and is not an
8928 and completing the appropriate organization; or employee of the filing entity. The
preparer must give you a copy of the
part. 3. The association, committee, joint form in addition to the copy to be filed
board of trustees, or other similar group with the IRS.
If you file an amended return to claim of representatives of the parties who
a refund or credit, the claim must state establish or maintain the plan, if the If you are a paid preparer, enter your
in detail the reasons for claiming the group health plan is established or Preparer Tax Identification Number
refund. In order for the IRS to promptly maintained jointly by one or more (PTIN) in the space provided. Include
consider your claim, you must explain employers and one or more employee your complete address. If you work for a
why you are filing the claim and provide organizations, or by two or more firm, you also must enter the firm’s
the appropriate supporting evidence. employers. name and the EIN of the firm. However,
See Regulations section 301.6402-2 for you cannot use the PTIN of the tax
more details. Include the suite, room, or other unit preparation firm in place of your PTIN.
numbers after the street number. If the You can apply for a PTIN online or by
post office does not deliver mail to the filing Form W-12, IRS Paid Preparer Tax
Specific Instructions street address and you have a P.O. box, Identification Number (PTIN)
Filer tax year. Enter the tax year of the show the box number instead of the Application and Renewal. For more
employer, entity, or individual on whom street address. information about applying for a PTIN
the tax is imposed by using the plan If the plan sponsor has a foreign online, visit the IRS website at
year beginning and ending dates address, enter the information in the www.irs.gov/ptin.
entered in Part I of Form 5500 or by following order: city or town, state or
using the tax year of the business return province, and country. Follow the Part I. Tax on Failure To
filed, if applicable. country's practice for entering the postal
code. Do not abbreviate the country Satisfy Continuation
Item A. Name and address of filer. name. Coverage Requirements
Enter the name and address of the
employer, individual, or other entity who Item E. Plan sponsor's EIN. Enter the Under Section 4980B
is liable for the tax. nine-digit employer identification Complete a separate Part I, Section A,
Include the suite, room, or other unit number (EIN) assigned to the plan lines 1 through 6, for each qualifying
numbers after the street number. If the sponsor. This should be the same event for which one or more failures to
post office does not deliver mail to the number used to file the Form 5500 satisfy continuation coverage
street address and you have a P.O. box, series return/report. requirements occurred during the
reporting period as a result of failures
show the box number instead of the Item F. Plan year ending. “Plan year” due to reasonable cause and not to
street address. is defined in Regulations section willful neglect. If multiple qualifying
If the entity has a foreign address, 54.9801-2. Enter eight digits in month/ events occurred with different
enter the information in the following date/year order. This number assists the noncompliance periods, complete lines
order: city or town, state or province, IRS in properly identifying the plan and 1 through 6 on a separate Part I for each
and country. Follow the country's time period for which the Form 8928 is qualifying event. Then complete a
practice for entering the postal code. Do being filed. For example, a plan year “summary” Form 8928 with items A
not abbreviate the country name.

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through G and enter the total amount of employed fewer than 20 employees on failures were not corrected before the
the excise tax on line 7 of that summary a typical business day. date a notice of examination of income
form and complete lines 8 through 11 Any governmental plan under section tax liability was sent from the IRS and
for all qualifying events as a result of 414(d). the failure or failures continued during
failures due to reasonable cause and Any church plan under section the examination period. The minimum
not to willful neglect. 414(e). excise tax under Part I, Section A, is
$15,000 if the failure or failures are
Complete a separate Part I, lines 12 Section A. Failures Due to determined to be more than de minimis.
through 14, for each qualifying event for Reasonable Cause and Not to
which one or more failures to satisfy Line 7. If you had more than one
Willful Neglect
continuation coverage requirements qualifying event during the reporting
occurred during the reporting period as If the failure or failures as a result of a period, complete lines 1 through 6 in a
a result of failures due to willful neglect particular qualifying event were due to separate Part I, Section A, for each
or otherwise not due to reasonable reasonable cause and not to willful qualifying event and enter the total from
cause. If multiple qualifying events neglect, complete Part I, Section A, line 6 from all copies of Part I, Section A,
occurred with different noncompliance lines 1 through 11. on line 7 of your summary form. See the
periods, complete lines 12 through 14 Line 1. Calculate the total number of discussion under Part I earlier.
on a separate Part I for each qualifying days of noncompliance within the Line 8. For a single employer plan,
event. Then complete a “summary” reporting period beginning on the date enter on line 8 the aggregate amount
Form 8928 with items A through G and the failure first occurred and ending on paid or incurred during the preceding
enter the total amount of the excise tax the earlier of the date the failure is tax year by the employer (or a
on line 15 of that summary form for all corrected or, at the latest, a date that is predecessor) for its group health plan.
failures that were due to willful neglect 6 months after the last day of the For a multiemployer plan, enter on this
or otherwise not due to reasonable maximum continuation coverage period line the amount paid or incurred during
cause. under the qualifying event that led to the the current tax year to provide medical
Write “Summary Form” at the top to failure. care, directly or through insurance or
indicate that this is a summary form and The noncompliance period may reimbursement.
attach all copies to it. TIP include portions of more than 1 Line 11. The maximum excise tax
You may report all failures on plan year (in the case of an payable during a tax year by third-party
TIP the same form if the failures employee benefit plan) or 1 tax year (in administrators, HMOs, and insurance
occurred during the same tax the case of an employer or third-party companies under Part I, Section A, is $2
year. administrator). In that case, only the million for all plans for failures due to
portion of the noncompliance period reasonable cause and not to willful
For purposes of Part I, a qualifying falling within that plan year or tax year neglect. For those entities, do not enter
event is any of the following. would be used to calculate the excise more than $2 million on this line for such
Death of the covered employee. tax due for that year. failures for all plans even if the
Termination or reduction of hours of aggregate excise tax owed for all
the covered employee's employment Line 4. No tax is due for any failure failures under Part I, Section A, is more
(other than for employee gross under Part I, Section A, if it is than $2 million.
misconduct). established to the satisfaction of the
Divorce or legal separation of the Secretary of the Treasury that no one Section B. Failures Due to
covered employee from the employee's liable for the tax knew, or exercising Willful Neglect or Otherwise
spouse. reasonable diligence would have Not Due to Reasonable Cause
Covered employee becoming entitled known, that the failure occurred.
to Medicare benefits. Additionally, no tax is due if the failure If the failure or failures as a result of a
Dependent child of the covered under Part I, Section A, was due to particular qualifying event were due to
employee ceasing to be a covered child reasonable cause and not due to willful willful neglect or otherwise not due to
under the terms of the plan. neglect and the failure was corrected reasonable cause, complete Part I,
Bankruptcy of the employer from during the 30-day period beginning on Section B, lines 12 through 15.
whose employment the covered the 1st date anyone liable for the tax Line 12. Calculate the total number of
employee retired. knew, or exercising reasonable days of noncompliance within the
diligence should have known, that the reporting period beginning on the date
Waiver of excise tax. The Secretary failure existed. the failure first occurred and ending on
may waive part or all of the excise tax For this purpose, a failure is treated the earlier of the date the failure is
under Part I, to the extent that payment as corrected if the failure is retroactively corrected or, at the latest, a date that is
of the tax would be excessive relative to undone to the extent possible and the 6 months after the last day of the
the failure involved. This only applies to qualified beneficiary to whom the failure maximum continuation coverage period
failures due to reasonable cause and relates is placed in a financial position under the qualifying event that led to the
not due to willful neglect. which is as good as such beneficiary failure.
Note. The tax under Part I will not apply would have been in had the failure not Line 15. If you had more than one
to the following. occurred. qualifying event during the reporting
Any failure of a group health plan if Line 5. The minimum excise tax under period, complete lines 12 through 14 in
the qualifying event occurred during the Part I, Section A, is $2,500 for each a separate Part I, Section B, for each
calendar year immediately following a qualified beneficiary for whom one or qualifying event and enter the total from
calendar year during which all more failures occurred if the failure or line 14 from all copies of Part I,
employers maintaining the plan normally Section B, on line 15 of your summary

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form. See the discussion under Part I 50 employees on business days during tax liability was sent from the IRS and
earlier. the preceding calendar year, and who the failure or failures continued during
employs at least 2 employees on the the examination period. The minimum
Part II. Tax on Failure To first day of the current plan year. Special excise tax under Part II, Section A, is
Meet Portability, Access, rules apply to employers not in $15,000 if the failure or failures are
existence in the preceding year. See determined to be more than de minimis.
and Renewability section 4980D(d)(2)(B).
Exception for church plans. The
Requirements Under
Section A. Failures Due to $2,500 (or $15,000, if applicable)
Section 4980D Reasonable Cause and Not to minimum excise tax does not apply to a
Complete a separate Part II, Section A, church plan, as defined in section
lines 17 through 23, for each failure to Willful Neglect
414(e). If your plan meets the
meet portability, access, and If the failure or failures were due to requirements for a church plan, enter
renewability requirements that occurred reasonable cause and not to willful “-0-” on this line and go to line 23.
during the reporting period that was due neglect, complete Part II, Section A,
to reasonable cause and not to willful lines 17 through 28. Line 24. If you had more than one
failure during the reporting period,
neglect. If multiple such failures Line 17. Calculate the total number of complete lines 17 through 23 in a
occurred with different noncompliance days of noncompliance within the separate Part II, Section A, for each
periods, complete lines 17 through 23 in reporting period beginning on the date failure and enter the total from line 23
a separate Part I, Section A, for each the failure first occurred and ending on from all copies of Part II, Section A, on
failure. Then complete a “summary” the date the failure is corrected. line 24 of your summary form. See the
Form 8928 with items A through G and
enter the total amount of the excise tax The noncompliance period may discussion under Part I earlier.
on line 24 of that summary form and TIP include portions of more than 1 Line 25. For a single employer plan,
complete lines 25 through 28 for all plan year (in the case of an enter on this line the aggregate amount
failures due to reasonable cause and employee benefit plan) or 1 tax year (in paid or incurred during the preceding
not to willful neglect. the case of an employer or third-party tax year by the employer (or a
administrator). In that case, only the predecessor) for its group health plan.
Complete a separate Part II, portion of the noncompliance period For a multiemployer plan, enter on this
Section B, lines 29 through 33, for each falling within that plan year or tax year line the amount paid or incurred during
failure to meet portability, access, and would be used to calculate the excise the current tax year to provide medical
renewability requirements that occurred tax due for that year. care, directly or through insurance or
during the reporting period that was due reimbursement.
to willful neglect or otherwise not due to Line 21. No tax is due for any failure
reasonable cause. If multiple failures under Part II, Section A, if it is Section B. Failure Due to Willful
occurred with different noncompliance established to the satisfaction of the Neglect or Otherwise Not Due
periods, complete lines 29 through 32 Secretary of the Treasury that no one to Reasonable Cause
on a separate Part II, Section B, for liable for the tax knew, or exercising
each failure. Then complete a reasonable diligence would have If the failure or failures were due to
“summary” Form 8928 with items A known, that the failure occurred. willful neglect or otherwise not due to
through G and enter the total amount of Additionally, no tax is due if the failure reasonable cause, complete Part II,
the excise tax on line 33 of that under Part II, Section A, was due to Section B, lines 29 through 33.
summary form for all such failures. reasonable cause and not due to willful Line 29. Calculate the total number of
neglect and the failure was corrected
Write “Summary Form” at the top to days of noncompliance within the
during the 30-day period beginning on
indicate that this is a summary form and reporting period beginning on the date
the first date anyone liable for the tax
attach all copies to it. the failure first occurred and ending on
knew, or exercising reasonable the date the failure is corrected.
Waiver of excise tax. The Secretary diligence would have known, that the
may waive part or all of the excise tax failure existed. Line 33. If you had more than one
failure during the reporting period,
under Part II, to the extent that payment For this purpose, a failure is treated complete lines 29 through 32 in a
of the tax would be excessive relative to as corrected if the failure is retroactively separate Part II, Section B, for each
the failure involved. This only applies to undone to the extent possible and the qualifying event and enter the total from
failures due to reasonable cause and person to whom the failure relates is line 32 from all copies of Part II,
not due to willful neglect. placed in a financial position which is as Section B, on line 33 of your summary
Exception for certain insured small good as such person would have been form. See the discussion under Part I
employer plans. If you are a small in had the failure not occurred. earlier.
employer who provides health In the case of a church plan, the
insurance coverage solely through a failure must be corrected before the Part III. Tax on Failure To
contract with a health insurance issuer, close of the correction period, as
Make Comparable Archer
you will not be liable for the excise tax defined under section 414(e)(4)(C).
under Part II for any failure (other than a MSA Contributions Under
failure under section 9811) that is solely Line 22. The minimum excise tax
the result of the health insurance under Part II, Section A, is $2,500 for Section 4980E
coverage offered by the issuer. each qualified beneficiary for whom one An employer is liable for tax under
or more failures occurred if the failure or section 4980E if he fails to make
“Small employer” is generally defined failures were not corrected before the comparable contributions to the Archer
as an employer who employed an date a notice of examination of income MSAs of all comparable participating
average of at least 2 but not more than

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employees for each coverage period under this part, to the extent that be retained as long as their contents
during the calendar year. payment of the tax would be excessive may become material in the
“Comparable contributions” are relative to the failure involved. This only administration of any Internal Revenue
contributions which are the same applies to failures due to reasonable law. Generally, tax returns and return
amount or which are the same cause and not to willful neglect. information are confidential, as required
by section 6103.
percentage of the annual deductible Controlled group. For purposes of this
limit under the high deductible health part, all persons treated as a single The time needed to complete and file
plan covering the employees. employer under section 414(b), (c), (m), this form will vary depending on
“Comparable participating or (o) will be treated as one employer. individual circumstances. The estimated
employees” are employees who are average time is:
eligible individuals covered under any Part V. Tax Due
Recordkeeping. . . 12 hr., 40 min.
high deductible health plan of the Make your check or money
employer, and who have the same order payable to “United States Learning about
category of coverage. Treasury” for the full amount the law or the
To determine whether contributions due. Attach the payment to your return. form. . . . . . . . . . . 4 hr., 0 min.
are comparable, see Regulations Write your name, identifying number, Preparing and
sections 54.4980G-1 through plan number, and “Form 8928, sending the form
54.4980G-7. Part(s)____” on your payment. to the IRS. . . . . . . 6 hr., 47 min.
Line 35. Enter the aggregate amount File at the address shown under Where
contributed to employees' Archer MSAs To File, earlier.
for tax years ending with or within the Comments and suggestions. We
calendar year. Privacy Act and Paperwork Reduc- welcome your comments about this
Waiver of excise tax. The Secretary tion Act Notice. We ask for the publication and your suggestions for
may waive part or all of the excise tax information on this form to carry out the future editions. You can send us
under this part, to the extent that Internal Revenue laws of the United comments from www.irs.gov/
payment of the tax would be excessive States. Taxpayers subject to the formspubs. Click on "More Information"
relative to the failure involved. This only provisions of sections 4980B, 4980D, and then on "Give us feedback." Or you
applies to failures due to reasonable 4980E, and 4980G are required to can write to:
cause and not to willful neglect. provide the information requested on
this form. Section 6109 requires you to Internal Revenue Service
Controlled group. For purposes of this provide your identifying number. If you Tax Forms and Publications
part, all persons treated as a single fail to provide this information in a timely 1111 Constitution Ave. NW
employer under section 414(b), (c), (m), manner, you may be liable for penalties. IR-6526
or (o) will be treated as one employer. Routine uses of this information include Washington, DC 20224
giving it to the Department of Justice for
Part IV. Tax on Failure To civil and criminal litigation, to other We respond to many letters by
Make Comparable HSA federal agencies as authorized by law, telephone. Therefore, it would be helpful
and to cities, states, the District of if you would include your daytime phone
Contributions Under Columbia, and U.S. commonwealths number, including the area code, in your
Section 4980G and possessions for use in correspondence. Although we cannot
An employer is liable for tax under administering their tax laws. We may respond individually to each comment
section 4980G if he fails to make also disclose this information to other received, we do appreciate your
comparable contributions to the HSAs countries under a tax treaty, to federal feedback and will consider your
of all comparable participating and state agencies to enforce federal comments as we revise our tax
employees for each coverage period nontax criminal laws, or to federal law products.
during the calendar year. enforcement and intelligence agencies
to combat terrorism. Ordering forms and publications.
Line 37. Enter the aggregate amount Visit www.irs.gov/ formspubs to
contributed to employees' HSAs for tax You are not required to provide the download forms and publications.
years ending with or within the calendar information requested on a form that is Otherwise, you can go to www.irs.gov/
year. subject to the Paperwork Reduction Act orderforms to order forms.
unless the form displays a valid OMB
Waiver of excise tax. The Secretary control number. Books or records
may waive part or all of the excise tax relating to a form or its instructions must

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