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COBRA Recipients [Line 12b].

Note:

Internal Revenue Manual Part 3. Submission Processing · 2026-10-03 edition · updated 2026-10-04 · United States

MU is a valid State Code for those businesses operating in multiple states.

1st Month

Liability Month 1

Enter the amount from box 16, Month 1 (form revisions 2012 through 2013 and 2017 and Later), box 17, Month 1 (form revisions 2009 through 2011), box 15, Month 1 (form revisions 2005-2008) or box 14, Month 1 (form revisions 2014 through 2016).

2nd Month

Liability Month 2

Enter the amount from box 16, Month 2 (form revisions 2012 through 2013 and 2017 and Later), box 17, Month 2 (form revisions 2009 through 2011), box 15, Month 2 (form revisions 2005-2008) or box 14, Month 2 (form revisions 2014 through 2016).

3rd Month

Liability Month 3

Enter the amount from box 16, Month 3 (form revisions 2012 through 2013 and 2017 and Later), box 17, Month 3 (form revisions 2009 through 2011), box 15, Month 3 (form revisions 2005-2008) or box 14, Month 3 (form revisions 2014 through 2016).

Final

Final Return

Enter an "X" if Part 3 box 17 (form revisions 2012 through 2013 and 2017 and Later), box 18 (form revisions 2009 through 2011), box 16 (form revisions 2005-2008) or box 15 (form revisions 2014 through 2016) is marked.

Seasonal

Seasonal Employer

Enter an "X" if Part 3 box 18 (form revisions 2012 through 2013, 2017 through 2021 (Rev. Mar 2021) and 2022 (Rev. Mar 2022) and Later), box 18a (form revision 2021 (Rev. June 2021), box 19 (form revisions 2009 through 2011), box 17 (form revisions 2005-2008) or box 16 (form revisions 2014 through 2016) is marked.

Eligible Emp. Ret. Cr. Recovery Startup [Line 18b]

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