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Addresses for mailing certain forms have changed since the forms were last published. The new mailing 
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Mailing address for Forms 706‐A, 706‐GS(D), 706‐GS(T), 706‐NA, 706‐QDT, 8612, 8725, 8831, 8842, 
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Internal Revenue Service Center 
Kansas City, MO 64999

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Taxpayers in the States Below                             Mail the Form to This Address

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                                          Return of Certain Excise Taxes Under 
Form  8928                              Chapter 43 of the Internal Revenue Code                                          OMB No. 1545-2146
(Rev. May 2016)                               (Under sections 4980B, 4980D, 4980E, and 4980G)
Department of the Treasury  
Internal Revenue Service      ▶ Information about Form 8928 and its separate instructions is at www.irs.gov/form8928.
Filer's tax year beginning                              ,                     and ending                                     , 
A Name of filer (see instructions)                                                                    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                            E   Plan sponsor’s EIN 

C Name of plan                                                                                        F   Plan year ending (MM/DD/YYYY) 

D Name and address of plan sponsor                                                                    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   Enter the total number of days of noncompliance in the reporting period .          . .    . . . .                1
  2   Enter the number of qualified beneficiaries for which a failure occurred
      as a  result of this qualifying event.  . . .   . . . .             . . . .     2 
  3   If you entered 2 or more on line 2, multiply line 1 by $200. Otherwise, multiply line 1 by $100                  3
  4   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        . . .    . .    . . . .                4 
  5   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- .           . . . . . . . .   . . .   . . . .             . . . . . .    . .    . . . .                5 
  6   Enter the smaller of line 3 or line 5 . . . .   . . . .             . . . . . .    . .    . . . .                6
  7   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  .                     7 
  8   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 .        . . . .   . . .   . . . .             . . . .     8 
  9   Multiply line 8 by 10% (0.10).    . .   . . .   . . . .             . . . . . .    . .    . . . .                9
10    Amount from section 4980B(c)(4) .       . . .   . . . .             . . . . . .    . .    . . . .              10
11    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 .         . . . . .    . .    . . . .              11 
Section B – Failures Due to Willful Neglect or Otherwise Not Due to Reasonable Cause 
12    Enter the total number of days of noncompliance in the reporting period .          . .    . . . .              12 
13    Enter the number of qualified beneficiaries for which a failure occurred
      as a result of this qualifying event .  . . .   . . . .             . . . .     13 
14    If you entered 2 or more on line 13, multiply line 12 by $200. Otherwise, multiply line 12 by $100.            14 
15    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 .    .              15 
Section C – Total Tax Due Under Section 4980B 
16    Add lines 11 and 15         . . . . .   . . .   . . . .             . . . . . .    . .    . . . . ▶ 126        16 
For Paperwork Reduction Act Notice, see instructions.                                 Cat. No. 37742T                  Form 8928 (Rev. 5-2016) 

Form 8928 (Rev. 5-2016)                                                                                                          Page 2 
Name of filer:                                                                              Filer’s EIN: 
Part II        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 29–32, for other failures to meet certain group health plan 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
17   Enter the total number of days of noncompliance in the reporting period .       .  . . .  .    .                  17 
18   Enter the number of individuals to whom the failure applies         . .   .     18 
19   Multiply line 17 by line 18.         . . . . . . . . . . .          . .   .     19 
20   Multiply line 19 by $100 .           . . . . . . . . . . .          . .   . . . .  . . .  .    .                  20 
21   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
     22. Otherwise, enter the amount from line 20 on line 23 and go to line 24 .     .  . . .  .    .                  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- .     . . .  . . .  .    .                  22 
23   Enter the smaller of line 20 or line 22 .    . . . . . . .          . .   . . . .  . . .  .    .                  23 
24   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      .    .                  24 
25   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. . .   25 
26   Multiply line 25 by 10% (0.10) .         . . . . . . . . .          . .   . . . .  . . .  .    .                  26 
27   Amount from section 4980D(c)(3) .          . . . . . . . .          . .   . . . .  . . .  .    .                  27 
28   Enter the smallest of lines 24, 26, or 27 .    . . . . . .          . .   . . . .  . . .  .    .                  28 
Section B – Failures Due to Willful Neglect or Otherwise Not Due to Reasonable Cause 
29   Enter the total number of days of noncompliance in the reporting period .       .  . . .  .    .                  29 
30   Enter the number of individuals to whom the failure applies         . .   .     30 
31   Multiply line 29 by line 30.         . . . . . . . . . . .          . .   .     31
32   Multiply line 31 by $100 .           . . . . . . . . . . .          . .   . . . .  . . .  .    .                  32 
33   If there was more than one failure, add the amounts shown on line 32 of all forms, and enter 
     the total on a single “summary” form. Otherwise, enter the amount from line 32 above      .    .                  33 
Section C – Total Tax Due Under Section 4980D 
34   Add lines 28 and 33          . .     . . . . . . . . . . .          . .   . . . .  . . .  .    . ▶        127     34 
Part III       Tax on Failure To Make Comparable Archer MSA Contributions Under Section 4980E
35   Aggregate amount contributed to Archer MSAs of employees within calendar year.         .  .    .                  35
36   Total tax due under section 4980E. Multiply line 35 by 35% (0.35)         . . . .  . . .  .    . ▶        128     36 
Part IV        Tax on Failure To Make Comparable HSA Contributions Under Section 4980G 
37   Aggregate amount contributed to HSAs of employees within calendar year .           . . .  .    .                  37
38   Total tax due under section 4980G. Multiply line 37 by 35% (0.35) .         . . .  . . .  .    . ▶        137     38 
Part V         Tax Due or Overpayment
39   Add lines 16, 34, 36, and 38.          . . . . . . . . . .          . .   . . . .  . . .  .    .                  39 
40   Enter amount of tax paid with Form 7004        . . . . . .          . .   . . . .  . . .  .    .                  40 
41   Tax due.    Subtract line 40 from line 39. If less than zero, enter -0-, and go to line 42. If the result 
     is greater than zero, enter here and attach a check or money order payable to “United     StatesTreasury.” 
     Write your name, identifying number, plan number, and “Form 8928” on your payment .  . .  .    .                  41 
42   Overpayment. Subtract line 39 from line 40       . . . . .          . .   . . . .  . . .  .    .                  42 
               Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my 
               knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer
Sign           has any knowledge.
Here           ▲                                                                 ▲                                  ▲
                 Your signature                                                    Telephone number                    Date
               Print/Type preparer's name           Preparer's signature                  Date                           PTIN
Paid                                                                                                  Check         if 
                                                                                                      self-employed
Preparer 
Use Only       Firm's name      ▶                                                                     Firm's EIN  ▶
               Firm's address  ▶                                                                      Phone no.
                                                                                                                       Form 8928 (Rev. 5-2016)