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Form 8453R: Electronic Filing Declaration for Form 8963
IRS Form 8453‑R is the Electronic Filing Declaration for Form 8963 that authenticates an electronic Report of Health Insurance Provider Information; it must be uploaded with Form 8963 when filing electronically for the 2020 calendar year.
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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 that authenticates an electronic Report of Health Insurance Provider Information; it must be uploaded with Form 8963 when filing electronically for the 2020 calendar year.
Risk Radar
Scan points- 1Submitting the report without a signed Form 8453‑R invalidates the filing.
- 2Submitting the report without the officer’s signature on Form 8453‑R.
- 3Leaving the signature date blank on the declaration.
- 4Omitting the officer’s title or printed name from the form.
- 5Failing to provide a daytime telephone or fax number when required.
Plain English
Form 8453‑R is a short declaration that you sign to prove the electronic health‑insurance report (Form 8963) is correct. You create a PDF of the signed form and send it together with the electronic report.
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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What this form is for
- Use this form when you file Form 8963 electronically for the 2020 calendar year and need to authenticate the electronic filing.
- Do not use it when you are not filing Form 8963 electronically.
- Check Form 8963 instead when you need to submit the Report of Health Insurance Provider Information.
Form selector
Use this form or another form?
Filing Form 8963 on paper
Paper filing does not require an electronic declaration
✓ Verify that the filing method is paper
Submitting a health‑insurance report for a year other than 2020
Different years may have updated forms or requirements
✓ Confirm the correct year’s form is used
Designated entity selected by the IRS for fee payment
The designated entity receives IRS communications about the ACA fee
✓ Confirm the designated entity’s consent on the report
Deadline or filing window
The source does not specify a filing deadline.
Checklist
What you need before filling it out
Signature of officer
Officer's handwritten signature · Signature line on Form 8453‑R
Date
Current date of signing · Date field on Form 8453‑R
Title
Officer's official title · Title line on Form 8453‑R
Print name of signing official
Printed name of officer · Print‑name line on Form 8453‑R
Daytime telephone number
Contact phone number · Telephone number field on Form 8453‑R
Before you submit
- 1Verify the form is the Rev. January 2020 edition
- 2Enter the organization’s name and EIN
- 3Select the appropriate officer title from the authorized list
- 4Print the officer’s name accurately
- 5Enter the signing date
- 6Provide a daytime telephone number
- 7Sign the form with a clear handwritten signature
- 8Scan the completed form to create a PDF
- 9Upload the PDF together with the electronic Form 8963
- 10Confirm the PDF is legible and all fields are visible
How to file this form
- 1Complete all required fields on Form 8453‑R
- 2Sign and date the form as an authorized officer
- 3Scan the signed form to generate a PDF file
- 4Upload the PDF with the electronic Form 8963 submission
- 5Verify that the IRS acknowledges receipt of the combined filing
Known limitations
- 1Does not apply to paper filings of Form 8963
- 2Does not apply to electronic filings for calendar years other than 2020
- 3Does not apply when the organization is not a controlled‑group member subject to the ACA fee
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->Form 8453‑R is the Rev. January 2020 edition and the PDF directs users to www.irs.gov/Form8453R for the latest information.
What changed or needs a fresh check
- Edition date — confirm the revision reads January 2020
- Fee — Not stated in the official source
- Mailing address — Not stated in the official source
- Signature — confirm the signature is by the president, vice president, treasurer, assistant treasurer, chief accounting officer, or another authorized officer
Quick Facts
Downloads
After you file
- 1Retain a copy of the signed Form 8453‑R PDF for your records
- 2Keep related Form 8963 documentation together with the form copy
- 3Store the records for as long as they may become material in IRS administration
- 4Watch for an electronic acknowledgment from the IRS confirming receipt
- 5If an error is identified, correct the report by filing an amended Form 8963 with a new Form 8453‑R
Sources
- SRCForm p.1 — revision date is January 2020
- SRCForm p.1 — purpose: authenticate electronic filing of Form 8963
- SRCForm p.1 — filing requirement: upload Form 8453‑R with electronically filed Form 8963
- SRCForm p.1 — signature must be by president, vice president, treasurer, assistant treasurer, chief accounting officer, or other authorized officer
- SRCForm p.1 — create a PDF of the completed Form 8453‑R and upload it with Form 8963
- SRCForm p.1 — officer’s signature allows IRS to disclose acceptance and delay reasons
Common confusion points
Do I need to mail Form 8453‑R?
The form is uploaded, not mailed.
→ Confirm that you are attaching the PDF to the electronic Form 8963
Can I use a scanned signature?
The form requires a handwritten signature on the original.
→ Ensure the scanned signature is clear and originates from a handwritten signature
Who is allowed to sign?
Multiple officer titles are listed, causing uncertainty.
→ Verify the signer’s title matches one of the authorized titles in the declaration section
Is a fax number required?
The fax field is present but the instructions do not mandate it.
→ Leave the fax field blank if no fax number is applicable
What if the designated entity is chosen by the IRS?
The text states consent is deemed given, which can be confusing.
→ Confirm the designated entity choice on the electronic report
Do I need to include the ACA fee amount on the form?
The fee amount is not shown on Form 8453‑R.
→ Refer to ACA section 9010 for the correct fee calculation
Workflow map
Related forms and next steps
Before
Current
After
Often used with
⚠ If something goes wrong
- Form 8963 — amend or correct the report as needed
Questions about IRS Form 8453R
What is IRS Form 8453R used for?
Form 8453‑R is a short declaration that you sign to prove the electronic health‑insurance report (Form 8963) is correct. You create a PDF of the signed form and send it together with the electronic report.
Who must file IRS Form 8453R?
Anyone who files Form 8963 electronically for the 2020 calendar year must upload Form 8453‑R with that report.
What information does IRS Form 8453R require?
Form 8453‑R collects the officer’s signature, date, title, printed name, daytime telephone and fax numbers, and includes a per‑jury declaration that the electronic report is true, correct, and complete.
Where do I file IRS Form 8453R?
Upload the signed PDF of Form 8453‑R together with the electronically filed Form 8963; do not mail it.
How do I complete IRS Form 8453R?
Complete Form 8453‑R by entering the officer’s name, title, date, and contact information, then sign the declaration. Scan the signed page to create a PDF file. Upload that PDF along with the electronic Form 8963 submission. Ensure the signing officer is authorized (president, VP, treasurer, assistant treasurer, chief accounting officer, or another authorized officer).
What happens if IRS Form 8453R is filed incorrectly?
If the form is not signed and uploaded, the IRS will treat the electronic report as incomplete and it will not be considered filed.
Do I need to mail Form 8453‑R?
The form is uploaded, not mailed. Confirm that you are attaching the PDF to the electronic Form 8963
Can I use a scanned signature?
The form requires a handwritten signature on the original. Ensure the scanned signature is clear and originates from a handwritten signature
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