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Federal COBRA Recapture Statement
Extracted from PDF file 2023-federal-form-14199.pdf, last modified January 2011COBRA Recapture Statement
Department of the Treasury — Internal Revenue Service Form 14199 (January 2011) COBRA Recapture Statement Complete the following information Taxpayer Name Social Security Number Daytime telephone number (including area code) ( ) - Complete the following information , under penalties of perjury, certify that I did not meet the I, (Print Name) requirements, as explained in the enclosed letter and Publication 502, for recapturing COBRA premium assistance, for the 2009 tax year. I did not meet the requirements because: NOTE: If you are not required to recapture your COBRA premium assistance because of the modified adjusted gross income calculation, please send us a completed copy of the worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers (also included with the letter), when you send us this completed Form. Signature Catalog Number 57048S Date www.irs.gov Form 14199 (Rev. 1-2011)
Form 14199 (Rev. 1-2011)
More about the Federal Form 14199 Other TY 2023
We last updated the COBRA Recapture Statement in February 2024, so this is the latest version of Form 14199, fully updated for tax year 2023. You can download or print current or past-year PDFs of Form 14199 directly from TaxFormFinder. You can print other Federal tax forms here.
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Form Sources:
The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 14199 from the Internal Revenue Service in February 2024.
Historical Past-Year Versions of Federal Form 14199
We have a total of eleven past-year versions of Form 14199 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:
2023 Form 14199
Form 14199 (Rev. 1-2011)
2022 Form 14199
Form 14199 (Rev. 1-2011)
2021 Form 14199
Form 14199 (Rev. 1-2011)
2020 Form 14199
Form 14199 (Rev. 1-2011)
2019 Form 14199
Form 14199 (Rev. 1-2011)
2018 Form 14199
Form 14199 (Rev. 1-2011)
2017 Form 14199
Form 14199 (Rev. 1-2011)
2016 Form 14199
Form 14199 (Rev. 1-2011)
2015 Form 14199
Form 14199 (Rev. 1-2011)
2012 Form 14199
Form 14199 (Rev. 1-2011)
2011 Form 14199
Form 14199 (Rev. 1-2011)
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