Form (Rev. May 2016) Department of the Treasury Internal Revenue Service 8928 Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code (Under sections 4980B, 4980D, 4980E, and 4980G) Information OMB No. 1545-2146 about Form 8928 and its separate instructions is at www.irs.gov/form8928. Filer's tax year beginning A Name of filer (see instructions) , and ending , B Filer's employer identification number (EIN) Number, street, and room or suite no. (if a P.O. box, see instructions) City or town, state or province, country, and ZIP or foreign postal code C D Name of plan Name and address of plan sponsor E Plan sponsor's EIN F Plan year ending (MM/DD/YYYY) G Plan number Part I Tax on Failure To Satisfy Continuation Coverage Requirements Under Section 4980B Complete a separate Part I, lines 1 through 6, for failures due to reasonable cause and not to willful neglect, and a separate Part I, lines 12 through 14, for other failures, for each qualifying event for which one or more failures to satisfy continuation coverage requirements that occurred during the reporting period (see instructions). Section A ­ Failures Due to Reasonable Cause and Not to Willful Neglect For IRS Use Only 1 2 3 4 Enter the total number of days of noncompliance in the reporting period . . . . . . . Enter the number of qualified beneficiaries for which a failure occurred as a result of this qualifying event . . . . . . . . . . . . 2 If you entered 2 or more on line 2, multiply line 1 by $200. Otherwise, multiply line 1 by $100 If the failure was not discovered despite exercising reasonable diligence or was corrected within the correction period and was due to reasonable cause, enter -0- here, and go to line 5. Otherwise, enter the amount from line 3 on line 6 and go to line 7 . . . . . . . . . If the failure was not corrected before the date a notice of examination of income tax liability was sent to the employer and the failure continued during the examination period, multiply $2,500 by the number of qualified beneficiaries for whom one or more failures occurred (multiply by $15,000 to the extent the violations were more than de minimis for a qualified beneficiary). If the failures were corrected before the date a notice of examination was sent, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . Enter the smaller of line 3 or line 5 . . . . . . . . . . . . . . . . . . . . If there was more than one qualifying event, add the amounts shown on line 6 of all forms, and enter the total on a single "summary" form. Otherwise, enter the amount from line 6 above . Enter the aggregate amount paid or incurred during the preceding tax year for a single employer group health plan or the amount paid or incurred during the current tax year for a multiemployer health plan to provide medical care . . . . . . . . . . . . . . . . 1 3 4 5 6 7 8 5 6 7 9 10 11 8 Multiply line 8 by 10% (0.10) . . . . . . . . . . . . . . . . . . . . . . Amount from section 4980B(c)(4) . . . . . . . . . . . . . . . . . . . . Enter the smallest of lines 7, 9, or 10. For a third-party administrator, HMO, or insurance company, the amount you enter on this line filed for all plans you administer during the same tax year cannot exceed $2 million; reduce the amount you would otherwise enter on this line to the extent the amount for all plans would exceed this limit . . . . . . . . . . . . Enter the total number of days of noncompliance in the reporting period . . . . . . . Enter the number of qualified beneficiaries for which a failure occurred as a result of this qualifying event . . . . . . . . . . . . 13 If you entered 2 or more on line 13, multiply line 12 by $200. Otherwise, multiply line 12 by $100. If there was more than one qualifying event, add the amounts shown on line 14 of all forms, and enter the total on a single "summary" form. Otherwise, enter the amount from line 14 above . . Add lines 11 and 15 . . . . . . . . . . . . . . . . . . . . . . . . 9 10 11 12 Section B ­ Failures Due to Willful Neglect or Otherwise Not Due to Reasonable Cause 12 13 14 15 14 15 126 16 Form 8928 (Rev. 5-2016) Section C ­ Total Tax Due Under Section 4980B 16 For Paperwork Reduction Act Notice, see instructions. Cat. No. 37742T American LegalNet, Inc. www.FormsWorkFlow.com Form 8928 (Rev. 5-2016) Page 2 Name of filer: Part II Filer's EIN: Tax on Failure To Meet Portability, Access, Renewability, and Other Requirements Under Section 4980D Complete a separate Part II, lines 17 through 23, for failures due to reasonable cause and not to willful neglect, and a separate Part II, lines 29­32, for other failures to meet certain group health plan requirements that occurred during the reporting period (see instructions). For IRS Use Only Section A ­ Failures Due to Reasonable Cause and Not to Willful Neglect 17 18 19 20 21 Enter the total number of days of noncompliance in the reporting period . . . . Enter the number of individuals to whom the failure applies . . . 18 Multiply line 17 by line 18 . . . . . . . . . . . . . . . 19 Multiply line 19 by $100 . . . . . . . . . . . . . . . . . . . . If the failure was not discovered despite exercising reasonable diligence or was within the correction period and was due to reasonable cause, enter -0- here, and 22. Otherwise, enter the amount from line 20 on line 23 and go to line 24 . . . . . . . 17 ... corrected go to line ... 20 21 22 If the failure was not corrected before the date a notice of examination of income tax liability was sent to the employer and the failure continued during the examination period, multiply $2,500 by the number of qualified beneficiaries for whom one or more failures occurred (multiply by $15,000 to the extent the violations were more than de minimis for a qualified beneficiary). If the failures were corrected before the date a notice of examination was sent, enter -0- . . . . . . . . . Enter the smaller of line 20 or line 22 . . . . . . . . . . . . . . . . . . . If there was more than one failure, add the amounts shown on line 23 of all forms, and enter the total on a single "summary" form. Otherwise, enter the amount from line 23 above . . Enter the aggregate amount paid or incurred during the preceding tax year for a single employer group health plan or the amount paid or incurred during the current tax year for a multiemployer health plan to provide medical care . . . Multiply line 25 by 10% (0.10) . . . . Amount from section 4980D(c)(3) . . . Enter the smallest of