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Official form guide
Form 14199: COBRA Recapture Statement
IRS Form 14199 is a COBRA Recapture Statement used to certify that the filer did not meet requirements for recapturing COBRA premium assistance for the 2009 tax year.
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IRS Form 14199 - COBRA Recapture Statement
IRS Form 14199 is a COBRA Recapture Statement used to certify that the filer did not meet requirements for recapturing COBRA premium assistance for the 2009 tax year.
Risk Radar
Scan points- 1Failure to certify that you did not meet the requirements is the highest risk on Form 14199.
- 2Filing without providing the Taxpayer Name and Social Security Number on Form 14199.
- 3Certifying that requirements were met when they were not, or vice versa.
- 4Omitting the specific reason why COBRA premium assistance was not recaptured.
- 5Failing to sign the form under penalty of perjury.
Plain English
This form tells the IRS that you are not eligible to get back some of your COBRA premium assistance money for the 2009 tax year. You certify this is true under penalty of perjury, confirming why you did not meet the necessary requirements.
Submission Date
- Filing date: 2012-07-17 00:00:00
- Preparation window: collect IDs, supporting records, and signatures in advance.
- Final review: verify names, dates, and required fields before submission.
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What this form is for
- Use this form when certifying that the filer did not meet the requirements for recapturing COBRA premium assistance for the 2009 tax year.
- Do not use Form 14199 if you met the requirements for recapturing COBRA premium assistance for the 2009 tax year.
- Check the worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers instead when your non-recapture status is due to modified adjusted gross income calculation.
Form selector
Use this form or another form?
COBRA assistance recapture not due to higher income
Required if the filer does not meet requirements because of the modified adjusted gross income calculation.
✓ Verify instructions.
Worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers
General certification of non-recapture (standard)
Used when certifying that requirements were not met, as explained in the enclosed letter and Publication 502.
✓ Ensure all fields are completed.
Filing status is unclear or needs verification
Use this form to certify non-meeting of recapture requirements for the 2009 tax year.
✓ Check accompanying letter.
Not stated in the official source
Deadline or filing window
The form certifies non-compliance for the 2009 tax year. While no specific filing deadline date is given, this certification must be submitted with the enclosed letter when required. No extension period is mentioned in the excerpt.
Checklist
What you need before filling it out
Taxpayer Name
The filer's full name · Form 14199, Line 1
Social Security Number
The filer's SSN · Form 14199, Line 2
Daytime telephone number
A contact phone number including area code · Form 14199, Line 3
Certification statement
The declaration that requirements were not met for the 2009 tax year · Form 14199, Certification Block
Reason for non-recapture
Specific explanation of why requirements were not met (e.g., modified AGI) · Form 14199, NOTE section
Before you submit
- 1Complete the Taxpayer Name and Social Security Number fields.
- 2Provide a Daytime telephone number including the area code.
- 3Print the filer's name in the designated space (I, ____).
- 4Certify under penalties of perjury that requirements were not met for the 2009 tax year.
- 5Clearly state the reason(s) why requirements were not met in the NOTE section.
- 6Sign and date the form.
- 7If applicable, include a completed worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers.
How to file this form
- 1Complete the Taxpayer Name, Social Security Number, and Daytime telephone number fields on Form 14199.
- 2Certify under penalties of perjury that the filer did not meet the requirements for recapturing COBRA premium assistance for the 2009 tax year.
- 3Detail the specific reason(s) in the NOTE section (e.g., modified adjusted gross income calculation).
- 4Sign and date the form, and if necessary, attach the required worksheet, before mailing to the IRS.
Known limitations
- 1Form 14199 (Rev. 1-2011) applies to certifying non-qualification for recapturing COBRA premium assistance specifically for the 2009 tax year.
- 2If the filer is not required to recapture COBRA premium assistance due to a modified adjusted gross income calculation, they must send a completed copy of the worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers along with Form 14199.
- 3The form requires certification under penalties of perjury that the filer did not meet the requirements as explained in the enclosed letter and Publication 502.
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 current edition is Revision 1 from January 2011 (Rev. 1-2011). The source does not point to a specific 'latest information' page, but it provides the version date and catalog number.
What changed or needs a fresh check
- Edition date — confirm the revision reads January 2011 (or Rev. 1-2011).
- Catalog Number — confirm it is 57048S.
- Filer Name/SSN — ensure the Taxpayer Name and Social Security Number are accurately completed.
- Signature — verify a signature is present before sending.
Quick Facts
Downloads
After you file
- 1Retain a completed copy of IRS Form 14199.
- 2The form must be signed and dated by the filer to certify the information.
- 3If sending via mail, include the required supporting worksheet when submitting the completed Form 14199.
- 4Confirm the revision date on the form reads 01/2011.
Sources
- SRCForm 14199 is officially titled COBRA Recapture Statement and has a revision date of January 2011 (Rev. 1-2011) [Form p.1].
- SRCThe form's Catalog Number is 57048S [Form p.1].
- SRCThe form is administered by the Department of the Treasury — Internal Revenue Service [Form p.1].
- SRCFiling requires providing Taxpayer Name, Social Security Number, and Daytime telephone number (including area code) [Form p.1].
- SRCThe filer certifies on Form 14199 that they did not meet requirements for recapturing COBRA premium assistance for the 2009 tax year [Form p.1].
- SRCA specific condition requiring recapture exemption is based on a modified adjusted gross income calculation [Form p.1].
Common confusion points
What if I am filing this for a year other than 2009?
Form 14199 is specific to the 2009 tax year, though it may be used in conjunction with other forms.
→ Confirm the form revision date or accompanying letter specifies the applicable tax year.
What do I need to include if my income calculation changes things?
If you are not required to recapture due to a modified adjusted gross income calculation, you must send the specific worksheet along with Form 14199.
→ Ensure the worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers is included.
Who fills out this form?
The filer (certifying party) completes IRS Form 14199.
→ Check if you are the taxpayer or a representative filing on behalf of the taxpayer.
What does 'under penalties of perjury' mean here?
It means the signer certifies that the statements made on Form 14199 regarding not meeting recapture requirements are true under penalty of perjury.
→ Verify your signature block includes this certification statement.
Where do I send it?
The source indicates filing with the Internal Revenue Service (IRS), but does not specify a mailing address.
→ Check the accompanying letter for the correct IRS service center address.
What if my name is different from my SSN holder's name?
The form requires separate fields for Taxpayer Name and Social Security Number, allowing for this distinction.
→ Ensure both the printed Taxpayer Name and the associated SSN are accurate.
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Questions about IRS Form 14199
What is IRS Form 14199 used for?
This form tells the IRS that you are not eligible to get back some of your COBRA premium assistance money for the 2009 tax year. You certify this is true under penalty of perjury, confirming why you did not meet the necessary requirements.
Who must file IRS Form 14199?
The filer must be an individual who certifies they did not meet the requirements for recapturing COBRA premium assistance for the 2009 tax year.
What information does IRS Form 14199 require?
The form collects the Taxpayer Name, Social Security Number, and Daytime telephone number. The certification section explains why the filer did not meet the requirements, noting if it was due to the modified adjusted gross income calculation.
Where do I file IRS Form 14199?
The completed Form 14199 must be sent with the enclosed letter. If required due to modified adjusted gross income calculation, the worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers must also accompany it.
How do I complete IRS Form 14199?
First, complete the basic information fields including Taxpayer Name, SSN, and phone number. Next, the individual must print their name and sign under penalty of perjury, certifying the non-meeting of COBRA premium assistance requirements for 2009. Finally, the filer must enter the date of signing.
What happens if IRS Form 14199 is filed incorrectly?
By signing Form 14199, the filer certifies that they did not meet the requirements; failure to certify accurately could lead to issues with recapturing the assistance.
What if I am filing this for a year other than 2009?
Form 14199 is specific to the 2009 tax year, though it may be used in conjunction with other forms. Confirm the form revision date or accompanying letter specifies the applicable tax year.
What do I need to include if my income calculation changes things?
If you are not required to recapture due to a modified adjusted gross income calculation, you must send the specific worksheet along with Form 14199. Ensure the worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers is included.
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