Form 8928- Return of Certain Excise Taxes Under Chapter 43 & TD 9457-Employer Comparable Contributions to HSAs and Requirement for filing excise taxes under sections 4980B, 4980D, 4980E and 4980G.

Forms and Documents

Document Name	Status
Form 8928 Form 8928 - Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code Form	Modified
REG 120476-07.pdf Supplementary Document	2015-08-31
TD 9457.pdf Supplementary Document	2015-08-31
1545-2146_Supporting_Statement_rev083115.doc Supporting Statement A	2015-08-31

IC Document Collections

IC ID	Document Title	Status
188460	Form 8928 - Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code Form	Modified

ICR Details

OMB Control No: 1545-2146	ICR Reference No: 201507-1545-006
Status: Historical Active	Previous ICR Reference No: 201203-1545-007
Agency/Subagency: TREAS/IRS	Agency Tracking No:
Title: Form 8928- Return of Certain Excise Taxes Under Chapter 43 & TD 9457-Employer Comparable Contributions to HSAs and Requirement for filing excise taxes under sections 4980B, 4980D, 4980E and 4980G.
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/27/2015
	Date Received in OIRA: 08/31/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2018	36 Months From Approved	10/31/2015
Responses	100	0	5,000
Time Burden (Hours)	2,348	0	2,500
Cost Burden (Dollars)	0	0	0

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Abstract: Form 8928 is used by employers, group health plans, HMOs, and third party administrators to report and pay excise taxes due for failures under sections 4980B, 4980D, 4980E, and 4980G. The information results from the requirement from TD 9457 to file a return for the payment of the excise taxes under section 4980B, 4980D, 4980E, and 4980G of the code.

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Authorizing Statute(s): US Code: 26 USC 4980G Name of Law: Failure of employer to make comparable health savings account contributions.
   US Code: 26 USC 4980E Name of Law: Failure of employer to make comparable Archer MSA contributions.
   US Code: 26 USC 4980D Name of Law: Failure to meet certain group health plan requirements.
   PL: Pub.L. 111 - 5 705 Name of Law: The American Recovery and Reinvestment Act
   PL: Pub.L. 104 - 191 402(a) Name of Law: Health Insurance Portability and Accountability Act of 1996
   US Code: 26 USC 4980B Name of Law: Failure to satisfy continuation coverage requirements of group health plans.
   PL: Pub.L. 100 - 647 3011(d) Name of Law: Technical Corrections Act of 1988
   PL: Pub.L. 104 - 191 301(c)(4)(A) Name of Law: Name of Law: Health Insurance Portability and Accountability Act of 1996
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 28764	05/19/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 52541	08/31/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Form 8928 - Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code	8928	Return of Certain Excise Taxes Under chapter 43 of the IRC

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	100	5,000	0	0	-4,900	0
Annual Time Burden (Hours)	2,348	2,500	0	0	-152	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The decrease of 152 burden hours is an adjustment to align Form 8928 (OMB No. 1545-2148) with the prescribing regulations (OMB # 1545-2146). This revision will eliminate double counting of burden hours. OMB control number 1545-2148 will be discontinued.

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Annual Cost to Federal Government: $25,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/31/2015

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