8453-R

Electronic Filing Declaration for Form 8963

Agency
IRS
Revision
Rev. January 2020
Fillable fields
7
Pages
1
Official source
IRS form page
Checked
October 21, 2026
Fill 8453-R online
Page 1 of form 8453-R

Form 8453-R: Electronic Filing Declaration for Form 8963

Form 8453-R is the Electronic Filing Declaration for Form 8963. The instructions say to use it to authenticate the electronic filing of Form 8963, Report of Health Insurance Provider Information. It is completed by an organization, and an officer of that organization signs it. It is not a form for individuals.

The declaration of officer covers the electronic report, the choice of a designated entity for a controlled group, and the fee imposed by ACA section 9010. The form says 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.

This is the January 2020 revision, and its text refers to reports filed in 2020. The form points to www.irs.gov/Form8453R for the latest information. You can fill out Form 8453-R free in your browser on this page and download it without an account.

What's on Form 8453-R

Calendar year

The calendar year the report covers, entered after "For calendar year 20".

Organization and EIN

The name of the organization and its employer identification number.

Declaration of Officer

A statement under penalties of perjury about the electronic report, the designated entity, the consent of controlled group members and liability for the ACA section 9010 fee.

Sign Here

The signature of the officer, the date and the officer's title.

Contact details

The printed name of the signing official, a daytime telephone number and a fax number.

How to fill out Form 8453-R

  1. 1

    Calendar year

    Complete the calendar year at the top of the form.

  2. 2

    Name and EIN

    Enter the name of the organization and its employer identification number.

  3. 3

    Officer signs

    An authorized officer reads the declaration, then signs and dates it and enters a title.

  4. 4

    Printed name and phone

    Print the signing official's name and add a daytime telephone number and fax number.

  5. 5

    Scan and upload

    Scan the signed form into a PDF file and transmit it with the electronic Form 8963 report.

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How and when Form 8453-R is filed

When to file

The form says Form 8453-R is filed with your electronically filed Form 8963.

How to file

The form says to create a PDF file of the completed Form 8453-R and upload it with Form 8963.

Report not complete without it

The form says the electronic report is not 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.

What the IRS may tell the transmitter

The officer's signature allows the IRS to disclose to the transmitter an acknowledgement that the report was accepted and the reason(s) for a delay in processing.

Latest information

This revision is dated January 2020. The form says to go to www.irs.gov/Form8453R for the latest information.

Related forms

Who completes Form 8453-R?

  • Form 8963 e-filers

    The form says that if you file Form 8963 electronically in 2020, Form 8453-R is uploaded with your report.

  • Single-person covered entities

    An officer of a single-person covered entity certifies the report on behalf of that entity.

  • Designated entities

    The declaration says the designated entity receives IRS communications about the ACA section 9010 fee and is to pay the fee on behalf of the controlled group.

  • Controlled group members

    The declaration says each member identified on the report consents to the choice of the designated entity, and members are jointly and severally liable for the fee.

  • Officers who may sign

    The president, vice president, treasurer, assistant treasurer, chief accounting officer, or any other officer authorized to sign the organization's report.

The organization that files Form 8963 electronically completes it, and an officer signs the declaration.

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Questions about Form 8453-R

What is Form 8453-R for?

The form says it is used to authenticate the electronic filing of Form 8963, Report of Health Insurance Provider Information.

Who signs Form 8453-R?

An officer of the organization: the president, vice president, treasurer, assistant treasurer, chief accounting officer, or another officer authorized to sign the report.

Do I mail Form 8453-R to the IRS?

The form says to create a PDF file of the completed form and upload it with the electronically filed Form 8963.

What happens if Form 8453-R is missing?

The form says the electronic report will not be considered complete, and therefore not considered filed, unless Form 8453-R is signed, scanned into a PDF and transmitted with it.

Which edition is this?

Rev. January 2020. Its text refers to Form 8963 filed electronically in 2020 and to controlled group members at the end of the day on December 31, 2019.