Independent form guide. BrieflyGo is not affiliated with or endorsed by IRS, USCIS, SSA, DOL, or any U.S. government agency. Official forms are sourced from public government websites.
Official form guide
Form 13560: Health Plan Administrator (HPA) Return of Funds
IRS Form 13560 is the Health Plan Administrator Return of Funds used by health plan administrators to return the Government’s portion of insurance premiums. The form must accompany any check or EFT reversal sent to the IRS.
Need help with Form 13560?
Open it in the AI Editor for field guidance, checks, and PDF export.
Need help? AI Editor guides you through every field of Form 13560.
Start filling →Form Overview
IRS Form 13560 - Health Plan Administrator (HPA) Return of Funds
IRS Form 13560 is the Health Plan Administrator Return of Funds used by health plan administrators to return the Government’s portion of insurance premiums. The form must accompany any check or EFT reversal sent to the IRS.
Risk Radar
Scan points- 1Submitting the payment without attaching Form 13560 can cause payment delays.
- 2Omitting the last four digits of the insured’s SSN in the Insured section.
- 3Failing to include a participant’s PIN when multiple participants are being returned.
- 4Not attaching Form 13560 to the check or EFT reversal as required.
- 5Sending the form to an incorrect address or fax number.
Plain English
This form tells the IRS how much money you are sending back for the government’s share of a health‑plan premium. You provide each person’s name, the last four digits of their SSN, why coverage ended, and the amount being returned. Then you mail or fax the form with the check or EFT reversal.
Submission Date
- Filing date: 2017-09-16 07:59:18
- Preparation window: collect IDs, supporting records, and signatures in advance.
- Final review: verify names, dates, and required fields before submission.
AI co-pilot
Fill it faster. Catch mistakes before you file.
What this form is for
- Use this form when returning the Government’s portion of the insurance premium.
- Do not use it when returning the participant’s portion of the insurance premium.
Form selector
Use this form or another form?
Returning Government portion via check
Ensures check is accompanied by required details
✓ Verify check is payable to US Treasury - HCTC
Reversing an EFT transaction
Provides documentation for bank reversal request
✓ Confirm EFT reversal request with bank
Returning funds for multiple participants as bulk payment
Requires detailed participant list attached to form
✓ Ensure detailed list includes all required fields
Deadline or filing window
Not stated in the official source.
Checklist
What you need before filling it out
Insured Name
Participant's full name · Insured section of Form 13560
SSN (last 4 digits)
Last four digits of insured's Social Security Number · Insured section of Form 13560
Date Coverage Ended
Coverage termination date · Insured section of Form 13560
Reason for Termination
Explanation code or text · Insured section of Form 13560
Total Amount Returned
Dollar amount of Government portion · Insured section of Form 13560
Before you submit
- 1Confirm the form version reads Rev. 5-2017 (May 2017).
- 2Enter Insured Name for each participant.
- 3Enter the last four digits of SSN in the Insured section.
- 4Provide Date Coverage Ended for each participant.
- 5State Reason for Termination for each participant.
- 6Record Total Amount Returned for each participant.
- 7Indicate Reason for Returned Funds for each participant.
- 8Attach the completed Form 13560 to the check or EFT reversal documentation.
- 9Make the check payable to "US Treasury - HCTC" if using a check.
- 10Mail the package to IRS Beckley Finance Center, PO Box 9002, Beckley WV 25802-9002.
- 11Fax the form to IRS HCTC at 855-780-9044 if using EFT reversal.
- 12Mark N/A in any fields that do not apply.
How to file this form
- 1Complete the Insured section for each participant, including name, last‑4 SSN, coverage end date, termination reason, amount returned, and reason for return.
- 2Attach the appropriate payment (check payable to US Treasury - HCTC or EFT reversal documentation) to the completed Form 13560.
- 3Select the submission method and either mail the package to the IRS Beckley Finance Center or fax the form to 855-780-9044 for EFT reversal.
- 4Send the mailing or fax and retain a copy of the form and payment receipt as proof of filing.
Known limitations
- 1Form 13560 does not apply to the participant’s portion of the insurance premium; only the Government’s portion may be returned.
- 2If more than one participant is impacted, a detailed listing of each participant with required data must be included.
- 3An internal document may be used instead of Form 13560 only if it provides all information requested on the form.
Field map
Compact field-by-field guide
General Info
2 items
Full legal name and taxpayer identification number (SSN or EIN).
Current mailing address.
Details
2 items
Complete all applicable sections of this form according to the official IRS instructions.
Enter the relevant dollar amount if this form involves tax calculation.
Certification
1 items
Read and acknowledge any certifications required by this form.
Signatures
1 items
Sign and date. Unsigned forms cannot be processed.
Almost done reviewing the fields?
Fillable formOpen in Editor->The form is Rev. 5-2017 (May 2017); the source does not indicate a newer revision.
What changed or needs a fresh check
- Edition date — confirm Rev. 5-2017 (May 2017) appears on the form
- Fee — Not stated in the official source
- Mailing address — confirm address is Internal Revenue Service Beckley Finance Center PO Box 9002 Beckley WV 25802-9002
- Signature — Not stated in the official source
- Fax number — confirm FAX #: 855-780-9044
Quick Facts
Downloads
After you file
- 1Retain the completed Form 13560 and any supporting payment documentation.
- 2Keep records as long as their contents may become material in the administration of any Internal Revenue law.
- 3Verify that the mailed check is payable to US Treasury – HCTC and that the address matches the IRS Beckley Finance Center mailing address.
- 4If an error is discovered, submit a corrected Form 13560 with the appropriate payment correction.
Sources
- SRCForm p.1 — the form is for returning the Government’s portion of the insurance premium ONLY.
- SRCForm p.1 — when completing the Insured section, fill in the last four digits of insured's social security number.
- SRCForm p.1 — the form MUST accompany all returned funds.
- SRCForm p.1 — if more than one participant is impacted, a detail listing of all participants with required data must be included.
- SRCForm p.1 — return funds by sending an HPA check payable to US Treasury - HCTC and mail to IRS Beckley Finance Center PO Box 9002 Beckley WV 25802-9002.
- SRCForm p.1 — for reversal of an EFT transaction, complete the form and fax to IRS - HCTC FAX #: 855-780-9044.
- SRCForm p.1 — for multiple individuals, you may send one bulk check with a detailed allocation list that includes all required fields.
- SRCForm p.1 — books or records relating to the form must be retained as long as their contents may become material in the administration of any Internal Revenue law.
Common confusion points
Do I need to include the participant’s portion on this form?
The form is only for returning the Government’s portion of the insurance premium.
→ Ensure only the Government’s portion is listed.
Should I enter the full Social Security Number?
Instructions specify filling in only the last four digits of the insured’s SSN.
→ Confirm only the last four digits are entered.
Can I send one check for multiple participants without any additional list?
When multiple participants are affected, a detailed list with required fields must accompany the bulk payment.
→ Attach a detailed participant list containing all required information.
Do I need to mail the form if I’m returning funds via an EFT reversal?
For EFT reversals, the form must be completed and faxed, not mailed.
→ Fax the completed form to IRS – HCTC at 855-780-9044.
Is the form required if my organization uses its own internal document that contains all required info?
The source permits an internal document in lieu of Form 13560 if it provides all requested information.
→ Verify the internal document includes every field required on Form 13560.
What address should I use when mailing the check?
The mailing address for checks is IRS Beckley Finance Center, PO Box 9002, Beckley WV 25802-9002.
→ Confirm the address matches the one listed in the form instructions.
Workflow map
Related forms and next steps
Before
Current
After
Often used with
⚠ If something goes wrong
- Form 13560 – required when returning an uncashed US Treasury check.
Questions about IRS Form 13560
What is IRS Form 13560 used for?
This form tells the IRS how much money you are sending back for the government’s share of a health‑plan premium. You provide each person’s name, the last four digits of their SSN, why coverage ended, and the amount being returned. Then you mail or fax the form with the check or EFT reversal.
Who must file IRS Form 13560?
Health Plan Administrators who are returning the Government’s portion of an insurance premium must file this form.
What information does IRS Form 13560 require?
The form collects the insured’s name, last four digits of the SSN, date coverage ended, reason for termination, total amount returned, reason for returned funds, and the participant’s PIN when multiple participants are involved.
Where do I file IRS Form 13560?
Mail the completed form with a check to Internal Revenue Service, Beckley Finance Center, PO Box 9002, Beckley, WV 25802‑9002. For EFT reversals, fax the form to IRS HCTC at 855‑780‑9044.
How do I complete IRS Form 13560?
Enter the insured’s name and the last four digits of the SSN in the Insured section. List each participant’s PIN, date coverage ended, reason for termination, total amount returned and reason for the return. Attach the check payable to US Treasury – HCTC or, for an EFT reversal, fax the form to the number above. Ensure the form is mailed or faxed with the payment, as the form must accompany all returned funds.
What happens if IRS Form 13560 is filed incorrectly?
Failure to provide the required information may delay or prevent receipt of the payment through the Automated Clearing House system.
Do I need to include the participant’s portion on this form?
The form is only for returning the Government’s portion of the insurance premium. Ensure only the Government’s portion is listed.
Should I enter the full Social Security Number?
Instructions specify filling in only the last four digits of the insured’s SSN. Confirm only the last four digits are entered.
Source transparency
Copyright & Licensing - US Government Forms
BrieflyGo links to and explains official public form sources. We are not a government agency, and this page is for general form guidance, not legal advice.
Understand the agreement before you sign it.
Review risky clauses in plain English, fix the document, and keep it moving toward signature.