Form 8453-R

(Rev. January 2015)

Declaration and Signature for Electronic Filing of 

Forms 8947 and 8963

Department of the Treasury 

Internal Revenue Service

▶ Information about Form 8453-R and its instructions is at www.irs.gov/form8453r.

For calendar year 20

OMB No. 1545-2253

Name of organization Employer identification number

Part I Type of Report

Check the box for the type of report being filed with Form 8453-R. 

Do not check more than one box in Part I. ▲

Form 8947 check here.

Form 8963 check here.

Part II Declaration of Officer

Under penalties of perjury, I declare that I have examined the electronic report, including accompanying statements, and, to the best of my knowledge and belief, 

it is true, correct, and complete. If I am signing as the designated entity, I also declare that the above named entity is the agent of an affiliated group or other 

designated entity (as per the instructions). I understand that the designated entity will receive IRS communications relating to the fee imposed by ACA section 

9008 or 9010 and is to pay this fee to the IRS on behalf of the controlled group. Each person that is a controlled group member at the end of the day on 

December 31, 2014, is jointly and severally liable for this fee. I further declare that each controlled group member identified on the electronic report consents to 

the choice of the designated entity indicated on that report. I further certify that I am an officer of the single-person covered entity or the designated entity, and 

that I am duly authorized to sign this report on behalf of that covered entity. Each person who is a controlled group member at the end of the day on December 

31, 2014, and would qualify as a covered entity in 2015 if it were a single-person covered entity is jointly and severally liable for any applicable penalty under 

ACA section 9010. (Where the designated entity is selected by the IRS, each entity in this report is deemed to consent to the choice of designated entity.)

Sign 

Here

▲

Signature of officer Date Title

Print name of signing official Daytime telephone number

Fax number

Future Developments

For the latest information about developments related to Form 

8453-R and its instructions, such as legislation enacted after they 

were published, go to www.irs.gov/form8453r. 

Purpose of Form

Use Form 8453-R to authenticate the electronic filing of:

• Form 8947, Report of Branded Prescription Drug Information, and

• Form 8963, Report of Health Insurance Provider Information.

Who Must File

If you are filing a Form 8947 or Form 8963 in 2015, you must upload 

Form 8453-R with your electronically filed report.

When To File

Form 8453-R must be filed with your electronically filed Form 8947 

or your Form 8963.

How To File

File Form 8453-R with the organization's electronically filed report. 

Use a scanner to create a PDF file of the completed form and 

upload it with your Form 8947 or your Form 8963.

Part II. Declaration of Officer

An electronically transmitted report will not be considered complete 

(and therefore not considered filed) unless Form 8453-R is signed 

by an officer of the organization, scanned into a PDF file, and 

transmitted with the report.

The officer's signature allows the IRS to disclose to the 

transmitter:

• An acknowledgement that the IRS has accepted the 

organization's electronically filed report, and

• The reason(s) for a delay in processing the report.

The declaration of officer must be signed and dated by:

• The president, vice president, treasurer, assistant treasurer, chief 

accounting officer, or

• Any other officer of the organization, such as an officer of the 

single-person covered entity or the designated entity, authorized to 

sign the organization's report.

Paperwork Reduction Act Notice. We ask for the information on this 

form to carry out the Internal Revenue laws of the United States. You

are required to give us the information. We need it to ensure that you 

are complying with these laws and to allow us to figure and collect the 

right amount of fees. 

You are not required to provide the information requested on a form 

that is subject to the Paperwork Reduction Act unless the form displays 

a valid OMB control number. Books or records relating to a form or its 

instructions must be retained as long as their contents may become 

material in the administration of any Internal Revenue law. The rules 

governing the confidentiality of this form are covered in Internal 

Revenue Code section 6103. 

The time needed to complete and file this form will vary 

depending on individual circumstances. The estimated average time 

is:

Recordkeeping . . . . . . . . . . . . 1 hr., 12 min.

Learning about the law or the form . . . . . . . 12 min.

Preparing and sending the form . . . . . . . . 13 min.

If you have comments concerning the accuracy of these time 

estimates or suggestions for making this form simpler, we would be 

happy to hear from you. You can send us comments from 

www.irs.gov/formspubs. Click on “More Information” and then on 

“Give us feedback.” You can also write to:

Internal Revenue Service 

Tax Forms and Publications 

1111 Constitution Ave. NW, IR-6526 

Washington, DC 20224

Do not send the form to this office. Instead, see How To File, 

earlier.

For Paperwork Reduction Act Notice, see instructions. Cat. No. 60914Z Form 8453-R (Rev. 1-2015)