0120 Form 8453-R (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f8453r.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(Rev. January 2020)

Department of the Treasury Internal Revenue Service

• Go to www.irs.gov/Form8453R for the latest information. OMB No. 1545-2253

Internal Revenue Service For calendar year 20

Name of organization Employer identification number

Declaration of Officer

Under penalties of perjury, I declare that I have examined the electronic report, including accompanying statements, and, to the best of my knowledge and belief, it is true, correct, and complete. If I am signing as the designated entity, I also declare that the above named entity is the agent of an affiliated group or other designated entity (as per the instructions). I understand that the designated entity will receive IRS communications relating to the fee imposed by ACA section 9010 and is to pay this fee to the IRS on behalf of the controlled group. Each person that is a controlled group member at the end of the day on December 31, 2019, is jointly and severally liable for this fee. I further declare that each controlled group member identified on the electronic report consents to the choice of the designated entity indicated on that report. I further certify that I am an officer of the single-person covered entity or the designated entity, and that I am duly authorized to sign this report on behalf of that covered entity. Each person who is a controlled group member at the end of the day on December 31, 2019, and would qualify as a covered entity in 2020 if it were a single-person covered entity is jointly and severally liable for any applicable penalty under ACA section 9010. (Where the designated entity is selected by the IRS, each entity in this report is deemed to consent to the choice of designated entity.)

Sign Here

Signature of officer Date Title

Print name of signing official Daytime telephone number

Fax number

Future Developments

For the latest information about developments related to Form 8453-R and its instructions, such as legislation enacted after they were published, go to www.irs.gov/Form8453R .

Purpose of Form

Use Form 8453-R to authenticate the electronic filing of Form 8963, Report of Health Insurance Provider Information.

Who Must File

If you file Form 8963 electronically in 2020, you must upload Form 8453-R with your report.

When To File

Form 8453-R must be filed with your electronically filed Form 8963.

How To File

Create a PDF file of the completed Form 8453-R and upload it with Form 8963.

Declaration of Officer

An electronically transmitted report will not be considered complete (and therefore not considered filed) unless Form 8453-R is signed by an officer of the organization, scanned into a PDF file, and transmitted with the report.

The officer’s signature allows the IRS to disclose to the transmitter:

• An acknowledgement that the IRS has accepted the organization’s electronically filed report, and

• The reason(s) for a delay in processing the report.

The declaration of officer must be signed and dated by:

• The president, vice president, treasurer, assistant treasurer, chief accounting officer; or

• Any other officer of the organization, such as an officer of the single-person covered entity or the designated entity, authorized to sign the organization’s report.

Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required to give us the information. We need it to ensure that you are complying with these laws and to allow us to figure and collect the right amount of fees.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. The rules governing the confidentiality of this form are covered in Internal Revenue Code section 6103.

The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is:

Recordkeeping . . . . . . . . . . . . 1 hr., 12 min.

Learning about the law or the form . . . . . . . 12 min.

Preparing and sending the form . . . . . . . . 13 min.

Comments. If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can send us comments from www.irs.gov/FormComments. Or you can write to the Internal Revenue Service, Tax Forms and Publications Division, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Don’t send the form to this office.

For Paperwork Reduction Act Notice, see instructions. Cat. No. 60914Z Form 8453-R (Rev. 1-2020)