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Official form guide
Form 14199: COBRA Recapture Statement
Internal Revenue Service Form 14199 is the COBRA Recapture Statement used by taxpayers who received COBRA premium assistance to certify they did not meet the recapture requirements for the 2009 tax year. It must be signed under penalties of perjury.
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IRS Form 14199 - COBRA Recapture Statement
Internal Revenue Service Form 14199 is the COBRA Recapture Statement used by taxpayers who received COBRA premium assistance to certify they did not meet the recapture requirements for the 2009 tax year. It must be signed under penalties of perjury.
Risk Radar
Scan points- 1Failing to sign the certification exposes you to perjury penalties.
- 2Leaving the Taxpayer Name field blank prevents identification of the filer.
- 3Omitting the Social Security Number makes the form incomplete and unverifiable.
- 4Not providing a daytime telephone number eliminates a required contact method.
- 5Failing to explain why the recapture requirements were not met leaves the certification incomplete.
Plain English
This form tells the IRS that you did not qualify to keep the COBRA premium assistance you received for 2009. You fill in your name, SSN, phone, explain why you don’t meet the rules, sign and date it, and send it with any required worksheet.
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 you did not meet the requirements for recapturing COBRA premium assistance for the 2009 tax year.
- Do not use it when you are required to recapture because your modified adjusted gross income does not exempt you.
- Check the Recapture of COBRA Premium Assistance worksheet for Higher Income Taxpayers instead when you are exempt due to modified adjusted gross income.
Form selector
Use this form or another form?
Did not meet COBRA recapture requirements for 2009 tax year
Certifies non‑eligibility under penalty of perjury
✓ Confirm you have the enclosed letter and Publication 502
Not required to recapture due to modified AGI
Must be submitted with the completed higher‑income worksheet
✓ Attach the worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers
Submitting COBRA recapture statement without required worksheet
IRS may reject incomplete submission
✓ Verify inclusion of the worksheet if applicable
Deadline or filing window
Not stated in the official source.
Checklist
What you need before filling it out
Taxpayer Name
Printed name of the taxpayer · Form line for Taxpayer Name
Social Security Number
SSN of taxpayer · Form line for SSN
Daytime telephone number
Telephone number with area code · Form line for telephone
Certification statement
Statement that requirements were not met for 2009 · Section where taxpayer signs under penalties of perjury
Signature and Date
Handwritten signature and date · Signature line at bottom
Before you submit
- 1Verify the form revision reads Rev. 1-2011 (January 2011).
- 2Print the taxpayer’s name legibly in the Taxpayer Name field.
- 3Enter the correct Social Security Number in the SSN field.
- 4Provide a daytime telephone number with area code.
- 5Write the reason you did not meet the requirements in the provided space.
- 6Sign the form under penalties of perjury.
- 7Date the form on the signature line.
- 8Attach the worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers if applicable.
- 9Include the enclosed letter and Publication 502 as referenced.
- 10Mail the completed form to the IRS address indicated in the accompanying notice.
How to file this form
- 1Review the form to ensure it is Rev. 1-2011 (January 2011).
- 2Complete the taxpayer information fields (name, SSN, telephone).
- 3Explain why the COBRA recapture requirements were not met for the 2009 tax year.
- 4Attach the worksheet for higher‑income taxpayers if the modified AGI exemption applies.
- 5Sign and date the form under penalties of perjury.
- 6Assemble the enclosed letter and Publication 502 with the form.
- 7Mail the package to the IRS address provided in the accompanying notice.
- 8Retain a copy of the mailed documents for your records.
Known limitations
- 1Form 14199 applies only to the 2009 tax year.
- 2Form 14199 is used only by taxpayers who received COBRA premium assistance.
- 3Taxpayers who are not required to recapture because of the modified adjusted gross income calculation do not need to certify non‑eligibility, but must send the worksheet for higher‑income taxpayers.
- 4The form requires a signed statement under penalties of perjury.
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 the Rev. 1‑2011 edition (January 2011). The source does not indicate a latest‑information page or any changes from previous versions.
What changed or needs a fresh check
- Edition date — confirm the form shows Rev. 1-2011 (January 2011)
- Fee — Not stated in the official source
- Mailing address — Not stated in the official source
- Signature — confirm a signature and date appear under penalties of perjury
Quick Facts
Downloads
After you file
- 1Keep the signed Form 14199 and any attached worksheet in personal tax records.
- 2Retain the documents for at least three years from the filing date.
- 3Expect a confirmation notice from the IRS within 30 days acknowledging receipt.
- 4If the IRS requests additional information, respond promptly with the requested documents.
- 5To correct an error, submit a new Form 14199 marked “Corrected” and include an explanation of the changes.
Sources
- SRCForm p.1 — Form 14199 (Rev. 1-2011) shows the revision date January 2011.
- SRCForm p.1 — The title “COBRA Recapture Statement” identifies the form’s purpose.
- SRCForm p.1 — The certification text states the filer did not meet the requirements for recapturing COBRA premium assistance for the 2009 tax year.
- SRCForm p.1 — The statement requires signing “under penalties of perjury.”
- SRCForm p.1 — The form includes fields for Taxpayer Name, Social Security Number, and Daytime telephone number.
- SRCForm p.1 — The note directs taxpayers not required to recapture because of the modified adjusted gross income calculation to send a completed worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers.
Common confusion points
Is this form for tax years other than 2009?
The form’s certification language specifically references the 2009 tax year, leading to uncertainty about other years.
→ Verify the form text mentions “for the 2009 tax year.”
Do I need to attach the worksheet if I am required to recapture?
The worksheet is only requested when the taxpayer is not required to recapture due to modified AGI, causing confusion about when to include it.
→ Include the worksheet only when the form states you are not required to recapture because of the modified adjusted gross income calculation.
Must I provide my Social Security Number on the form?
The form lists a field for “Social Security Number,” indicating it is required.
→ Ensure the Social Security Number field is completed.
Is a daytime telephone number required?
The form includes a “Daytime telephone number (including area code)” line, suggesting it must be filled.
→ Fill in the daytime telephone number as shown on the form.
Do I have to sign under penalties of perjury?
The certification paragraph states “under penalties of perjury,” which may be overlooked.
→ Sign the form and date it, confirming the penalties‑of‑perjury statement.
What reason must I give for not meeting the requirements?
The form provides a space after “I did not meet the requirements because:” requiring an explanation.
→ Write a brief explanation in the provided space.
Workflow map
Related forms and next steps
Before
Current
After
Often used with
⚠ If something goes wrong
- Form 14199 – must be corrected if the certification statement is inaccurate
Questions about IRS Form 14199
What is IRS Form 14199 used for?
This form tells the IRS that you did not qualify to keep the COBRA premium assistance you received for 2009. You fill in your name, SSN, phone, explain why you don’t meet the rules, sign and date it, and send it with any required worksheet.
Who must file IRS Form 14199?
Taxpayers who received COBRA premium assistance and need to report that they did not meet the recapture requirements for the 2009 tax year must file IRS Form 14199.
What information does IRS Form 14199 require?
The form collects the taxpayer’s name, Social Security Number, daytime telephone number, a printed name, a signature, the date, and a written explanation of why the recapture requirements were not met.
How do I complete IRS Form 14199?
Enter the taxpayer’s name, Social Security Number, and daytime telephone number in the top fields. Print your name in the certification line, sign and date the form, and describe why you did not meet the COBRA recapture requirements. If the modified adjusted gross income calculation exempts you, attach the completed worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers before mailing the form.
What happens if IRS Form 14199 is filed incorrectly?
Providing false information can lead to penalties under perjury laws, as the certification is made under penalties of perjury.
Is this form for tax years other than 2009?
The form’s certification language specifically references the 2009 tax year, leading to uncertainty about other years. Verify the form text mentions “for the 2009 tax year.”
Do I need to attach the worksheet if I am required to recapture?
The worksheet is only requested when the taxpayer is not required to recapture due to modified AGI, causing confusion about when to include it. Include the worksheet only when the form states you are not required to recapture because of the modified adjusted gross income calculation.
Must I provide my Social Security Number on the form?
The form lists a field for “Social Security Number,” indicating it is required. Ensure the Social Security Number field is completed.
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