0111 Form 14199 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f14199.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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Complete the following information

Taxpayer Name Social Security Number

Daytime telephone number (including area code)

( ) -

Complete the following information

I,

(Print Name)

, under penalties of perjury, certify that I did not meet the

requirements, as explained in the enclosed letter and Publication 502, for recapturing COBRA premium assistance, for the 2009 tax year.

I did not meet the requirements because:

NOTE: If you are not required to recapture your COBRA premium assistance because of the modified adjusted gross income calculation, please send us a completed copy of the worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers (also included with the letter), when you send us this completed Form.

Signature Date

Form 14199 (Rev. 1-2011)

Catalog Number 57048S

www.irs.gov