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OMB Control No: 1545-2148	ICR Reference No: 200911-1545-021
Status: Historical Active	Previous ICR Reference No: 200905-1545-024
Agency/Subagency: TREAS/IRS	Agency Tracking No:
Title: Form 8928 - Return of Certain Excise Taxes Under Chapter 43 of the Internal Revenue Code
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR: No
Type of Review Request: Emergency	Approval Requested By: 06/05/2009
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/14/2009
	Date Received in OIRA: 12/01/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2009	12/31/2009	12/31/2009
Responses	100	0	100
Time Burden (Hours)	2,348	0	1,858
Cost Burden (Dollars)	0	0	0

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.

Emergency Justfication: Code sections 4980B, 4980D, 4980E, and 4980G provide for an excise tax for certain failures by employers, group health plans, HMOs, and third party administrators related to group health benefits. Form 8928 will be used to calculate and remit the amount of excise tax owed under these sections in compliance with the Code. We have been developing the forms layout and its associated instructions with assistance from Chief Counsel. The instructions are in the final stages at this moment. An earlier request to OMB for Paperwork Reduction Act submission on the form and its instructions would have yielded incorrect results. As the form and instructions are needed for 2009, waiting the full 150 days for the process would hamper taxpayers from filing a timely tax return. A late availability of the form would not allow taxpayers to timely understand the new form and instructions. This would then place undue burden on both the taxpayer and the Service as extensions would have to be prepared by taxpayers and the Service would have to process them. Alternatively, the taxpayer could file their return on time and then have to file an amended return at a later date. This would also add undue taxpayer burden and burden the Service with additional processing costs for the second return.

Authorizing Statute(s): PL: Pub.L. 104 - 191 402(a). Name of Law: Health Insurance Portability and Accountability Act of 1996
   PL: Pub.L. 100 - 647 3011(d). Name of Law: Technical Corrections Act of 1988
   PL: Pub.L. 108 - 173 1201(d)(4)(A). Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003
   PL: Pub.L. 104 - 191 301(c)(4)(A). Name of Law: Health Insurance Portability and Accountability Act of 1996

Citations for New Statutory Requirements: PL: Pub.L. 108 - 173 1201(d)(4)(A). Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003

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

Federal Register Notices & Comments
Did the Agency receive public comments on this ICR? No

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

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	100	100	0
Annual Time Burden (Hours)	2,348	1,858	490
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

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

Burden Reduction Due to:

Short Statement: 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. Code sections 4980B, 4980D, 4980E, and 4980G provide for an excise tax for certain failures by employers, group health plans, HMOs, and third party administrators related to group health benefits. Form 8928 will be used to calculate and remit the amount of excise tax owed under these sections in compliance with the Code. The compliance with these Code sections results in an estimated increase in the burden hours by 490 hours.

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Jason Langley 2026224366

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