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        500,000 
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    500,000
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      States Treasury.” 
     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)