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Client Name - PCORI Fee Worksheet - page 2
Method 3 - Snapshot Factor Method
A.
Jan-15 1st of the month
Number of subscribers with self only-coverage (a)
373
Number of subscribers with other than self-only coverage (b)
564
Number of lives (a+(b*2.35))
1698.40
B.
Apr-15 1st of the month
Number of subscribers with self only-coverage (a)
365
Number of subscribers with other than self-only coverage (b)
562
Number of lives (a+(b*2.35))
1685.70
C.
Jul-15 1st of the month
Number of subscribers with self only-coverage (a)
357
Number of subscribers with other than self-only coverage (b)
574
Number of lives (a+(b*2.35))
1705.90
D.
Oct-15 1st of the month
Number of subscribers with self only-coverage (a)
358
Number of subscribers with other than self-only coverage (b)
573
Number of lives (a+(b*2.35))
1704.55
E.
Sum of all 4 quarters
6794.55
F.
Number of counts
4
G.
Average lives (E/F)
1698.64
H.
2015 Fee
$2.17
I.
Total Fee Due (amount remitted to IRS on Form 720)
$3,686.04
Employers need to complete:
● Company infomration and quarter ending June 2016
● Part II, IRS No. 133
○ Column (a) - enter "Avg number of lives covered for self-insured health plans" in
row 9c) or (d), depending on end of plan year
○ Column (b) - $2.08 or $2.17 in row (c) or (d), depending on end of plan year
○ Column (c) - enter total Fee (lives x $)
○ Tax Column - enter the amount of the fee (from Column (c))
● Part II, Line 2 - enter Total Tax (from Tax column on No. 133)
● Part III, Line 3 - enter Total Tax (from part II, Line 2)
● Part III, Line 10 - enter Balance Due (from Part III, Line 3)
● Signature section
● Payment voucher with "2nd Quarter" checked or file and pay electronically
○ If filing by mail, send the form, payment voucher and check to:
Department of the Treasury
Internal Revenue Service
Cincinnati, OH 45999-0009