Form 8928 — Return of Certain Excise Taxes Under Chapter 43

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f8928.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

Form

8928¶

(Rev. December 2025)

Department of the Treasury Internal Revenue Service

Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code

(Under sections 4980B, 4980D, 4980E, and 4980G) Go to www.irs.gov/Form8928 for instructions and the latest information.

OMB No. 1545-2146

Filer’s tax year beginning , and ending , A Name of filer (see instructions) B Filer’s employer identification

number (EIN)

Number and street (If a P.O. box, see instructions) Room or suite no.

City or town State or province Country 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

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

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

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

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

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

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

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 separate instructions. Cat. No. 37742T Form 8928 (Rev. 12-2025) Created 9/11/25

Form 8928 (Rev. 12-2025) 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 relates . . . 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

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

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 individuals to whom the failure relates (multiply by $15,000 to the extent the violations were more than de minimis for an individual). 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

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

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 relates . . . 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

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