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Form 8453R: Electronic Filing Declaration for Form 8963
IRS Form 8453-R is the Electronic Filing Declaration for Form 8963, used to authenticate electronic filings related to Health Insurance Provider Information for calendar year 20. Each person who is a controlled group member at the end of the day on December 31, 2019, is jointly and severally liable for this fee.
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IRS Form 8453R - Electronic Filing Declaration for Form 8963
IRS Form 8453-R is the Electronic Filing Declaration for Form 8963, used to authenticate electronic filings related to Health Insurance Provider Information for calendar year 20. Each person who is a controlled group member at the end of the day on December 31, 2019, is jointly and severally liable for this fee.
Risk Radar
Scan points- 1The report is not considered complete unless Form 8453-R is signed by an officer of the organization and transmitted as a PDF.
- 2Filing Form 8453-R without an officer's signature on the document.
- 3Not scanning the completed Form 8453-R into a PDF file before uploading.
- 4Omitting the organization’s Employer identification number when filing electronically.
- 5Failing to declare that the report is true, correct, and complete under penalty of perjury.
Plain English
This form certifies that an organization has electronically submitted Form 8963. By filing Form 8453-R, the filer declares that the report is true, correct, and complete under penalty of perjury. This declaration confirms who filed it and that the entity agrees to pay fees related to ACA section 9010.
Submission Date
- Filing date: 2020-01-28 22:13:20
- Preparation window: collect IDs, supporting records, and signatures in advance.
- Final review: verify names, dates, and required fields before submission.
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Glossary Terms
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What this form is for
- Use this form when electronically filing Form 8963, Report of Health Insurance Provider Information, for calendar year 20.
- Do not use it when filing Form 8963 on paper, as the declaration must be signed and scanned into a PDF to be considered complete.
- Check Form 8963 instead when reporting Health Insurance Provider Information.
Form selector
Use this form or another form?
Filing Form 8963 electronically
To authenticate the electronic filing of the report, which is required if you file Form 8963 in 2020.
✓ Confirm that Form 8453-R accompanies your digital submission.
Certifying a single-person covered entity's declaration
To declare that the signing officer is duly authorized to sign on behalf of that specific covered entity.
✓ Ensure the signatory meets the required criteria for authorization.
Filing as an affiliated group agent
If you are signing as the designated entity, this form allows declaration that the named organization is acting as an agent for another affiliated or designated entity.
✓ Verify that the designation aligns with your organizational structure.
Deadline or filing window
Form 8453-R must be filed with your electronically filed Form 8963. There is no separate deadline stated, but it applies to filings made in 2020. Each controlled group member at year-end 2019 is jointly and severally liable for the ACA section 9010 fee.
Checklist
What you need before filling it out
Purpose
Use Form 8453-R to authenticate the electronic filing of Form 8963, Report of Health Insurance Provider Information. · Purpose section on p.1
Filer Requirement
If you file Form 8963 electronically in 2020, you must upload Form 8453-R with your report. · Who Must File section on p.1
Declaration Signatory
The officer must be the president, vice president, treasurer, assistant treasurer, chief accounting officer; or any other authorized officer. · Declaration of Officer section on p.1
Liability Scope
Each person that is a controlled group member at the end of the day on December 31, 2019, is jointly and severally liable for this fee. · p.1 declaration text
Submission Method
Create a PDF file of the completed Form 8453-R and upload it with Form 8963. · How To File section on p.1
ACA Fee Context
The designated entity receives IRS communications relating to the fee imposed by ACA section 9010 and pays this fee on behalf of the controlled group. · p.1 declaration text
Before you submit
- 1Confirm the organization's Name and Employer identification number are correctly listed.
- 2Verify that the signing official has completed their Signature, Date, Title, Print name of signing official, Daytime telephone number, Fax number fields.
- 3Check that the declaration explicitly states the report is true, correct, and complete under penalties of perjury.
- 4If applicable, confirm the signer declares the organization is an agent for an affiliated or other designated entity.
- 5Verify that each controlled group member identified on the electronic report consents to the chosen designated entity.
- 6Ensure the declaration is signed by a duly authorized officer (President, VP, Treasurer, etc.).
- 7Confirm the completed Form 8453-R has been scanned into a PDF file before uploading.
How to file this form
- 1Complete all required fields on IRS Form 8453-R, including the Name of organization and Employer identification number.
- 2Have an authorized officer sign the declaration section and provide their Date, Title, Print name, contact information, etc.
- 3Scan the completed and signed Form 8453-R into a PDF file format.
- 4Upload the PDF copy of Form 8453-R along with your electronically filed Form 8963 to submit the declaration.
Known limitations
- 1The declaration of officer must be signed and dated by the president, vice president, treasurer, assistant treasurer, chief accounting officer; or any other officer authorized to sign.
- 2If the designated entity is selected by the IRS, each entity in the report is deemed to consent to the choice of designated entity.
- 3A paper submission will not be considered complete (and therefore not considered filed) unless Form 8453-R is signed by an officer, scanned into a PDF file, and transmitted with the report.
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 January 2020 (Rev. 1-2020). The source directs users to www.irs.gov/Form8453R for the latest information, but no specific changes from prior revisions are detailed in this excerpt.
What changed or needs a fresh check
- Edition date — confirm the revision date reads 01/20 (or Rev. January 2020).
- Fee liability — confirm each person who is a controlled group member at year-end 2019 is jointly and severally liable for the fee.
- Mailing address — confirm comments can be sent to Tax Forms and Publications Division, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224 (though do not send the form here).
- Signature — confirm the declaration must be signed by an officer of the organization.
Quick Facts
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After you file
- 1Retain books or records relating to Form 8453-R as long as their contents may become material in the administration of any Internal Revenue law.
- 2The IRS can use the officer’s signature on Form 8453-R to disclose an acknowledgement that the IRS has accepted the organization’s electronically filed report.
- 3The IRS can use the officer’s signature on Form 8453-R to disclose the reason(s) for a delay in processing the report.
- 4If filing paper copies, ensure you keep a copy of the completed and signed Form 8453-R.
Sources
- SRCForm 8453-R is the Electronic Filing Declaration for Form 8963 for calendar year 20 (Instructions p.1).
- SRCEach person that is a controlled group member at the end of December 31, 2019, is jointly and severally liable for this fee (Instructions p.1).
- SRCForm 8453-R must be filed with your electronically filed Form 8963 (Instructions p.1).
- SRCTo file Form 8453-R, create a PDF file of the completed form and upload it with Form 8963 (Instructions p.1).
- SRCThe declaration of officer must be signed by an officer of the organization to be complete (Instructions p.1).
- SRCThe estimated average time to prepare and send this form is 13 minutes (Instructions p.1).
Common confusion points
Who must file this form?
Organizations that file Form 8963 electronically for calendar year 20 must upload Form 8453-R with their report.
What is the penalty liability?
Each person who is a controlled group member at the end of December 31, 2019, and qualifies as a covered entity in 2020 if it were single-person, is jointly and severally liable for penalties under ACA section 9010.
How do I file this form?
Create a PDF file of the completed Form 8453-R and upload it with Form 8963.
What happens if you don't sign it?
An electronically transmitted report will not be considered complete (and therefore not considered filed) unless Form 8453-R is signed by an officer, scanned into a PDF file, and transmitted with the report.
Where do I send the form?
Do not send the form to the office listed in the Paperwork Reduction Act Notice; upload it electronically with Form 8963.
What if my organization has multiple people liable?
Each person that is a controlled group member at the end of December 31, 2019, is jointly and severally liable for this fee.
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Questions about IRS Form 8453R
What is IRS Form 8453R used for?
This form certifies that an organization has electronically submitted Form 8963. By filing Form 8453-R, the filer declares that the report is true, correct, and complete under penalty of perjury. This declaration confirms who filed it and that the entity agrees to pay fees related to ACA section 9010.
Who must file IRS Form 8453R?
Any organization that files Form 8963 electronically in 2020 must upload Form 8453-R with their report. Specifically, each person that is a controlled group member at the end of the day on December 31, 2019, is jointly and severally liable for this fee.
What information does IRS Form 8453R require?
The form collects organizational details such as the Name of organization and Employer identification number. It requires a Declaration of Officer to certify that the report is true, correct, and complete.
When is IRS Form 8453R due?
Form 8453-R must be filed with your electronically filed Form 8963. The source does not specify a separate deadline for filing this form, as it accompanies Form 8963.
Where do I file IRS Form 8453R?
The required method of filing is to create a PDF file of the completed Form 8453-R and upload it with Form 8963. For further developments, users should go to www.irs.gov/Form8453R.
How do I complete IRS Form 8453R?
First, fill out the organizational details and declaration information on Form 8453-R. Next, an authorized officer must sign this form. Finally, the completed form must be scanned into a PDF file and uploaded with your electronically filed Form 8963.
What happens if IRS Form 8453R is filed incorrectly?
If Form 8453-R is not signed by an officer of the organization or scanned into a PDF file before transmission, the electronically transmitted report will not be considered complete (and therefore not considered filed).
Who must file this form?
Organizations that file Form 8963 electronically for calendar year 20 must upload Form 8453-R with their report.
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