Taxpayer name and SSN
Boxes for the taxpayer name and Social Security number at the top of the page.
14199
COBRA Recapture Statement
- Agency
- IRS
- Revision
- Rev. 1-2011
- Fillable fields
- 8
- Pages
- 1
- Official source
- IRS form page
- Checked
- October 21, 2026
Form 14199: COBRA Recapture Statement
Form 14199, COBRA Recapture Statement, is a one-page IRS form that a taxpayer signs under penalties of perjury. In it the taxpayer certifies that they did not meet the requirements, as explained in the enclosed letter and Publication 502, for recapturing COBRA premium assistance for the 2009 tax year, and explains why.
The form refers to an enclosed letter, so it reaches the taxpayer together with an IRS letter, and the completed form goes back to the IRS. It asks for the taxpayer's name, Social Security number and daytime telephone number, a written reason and a signature.
The form has no separate instructions and prints no mailing address or deadline. You can fill out Form 14199 free in your browser on this page and download it without an account.
What's on Form 14199
Daytime telephone number
A space for a daytime telephone number including area code.
Certification statement
A sentence with a blank for the printed name, certifying under penalties of perjury that the requirements for recapturing COBRA premium assistance for the 2009 tax year were not met.
Reason
Lines after "I did not meet the requirements because:" for the explanation.
Note, signature and date
A note about the higher income worksheet, followed by the signature and date lines.
How to fill out Form 14199
- 1
Read the letter
The certification points to the requirements explained in the enclosed letter and Publication 502, so read the letter that came with the form first.
- 2
Name, SSN and phone
Enter the taxpayer name and Social Security number, then a daytime telephone number with area code.
- 3
Print your name
Print your name in the blank of the certification sentence about the 2009 tax year.
- 4
Explain why
On the lines after "I did not meet the requirements because:" write the reason recapture does not apply.
- 5
Add the worksheet if it applies
If the reason is the modified adjusted gross income calculation, the form asks for a completed copy of the higher income worksheet included with the letter.
- 6
Sign and date
Sign and date the form. The certification is made under penalties of perjury.
Why fill Form 14199 on indox
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- Fill the form right in your browser, no software to install
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- The official blank straight from the IRS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes and what to include
Where it goes
The form says to send the completed form to the IRS ("send us"). It prints no mailing address and refers to the letter enclosed with it.
Worksheet
The form says: "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."
Tax year
The certification on this revision is for the 2009 tax year.
Deadline and signature
The form prints no deadline. The taxpayer signs and dates it, and the certification is made under penalties of perjury.
Related forms
Who fills out Form 14199?
The taxpayer named on the form completes and signs it and sends it to the IRS. The form says it relates to the letter enclosed with it.
Official sources and the blank
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Questions about Form 14199
What is Form 14199?
A one-page COBRA Recapture Statement in which a taxpayer certifies under penalties of perjury that they did not meet the requirements for recapturing COBRA premium assistance for the 2009 tax year.
How does someone get Form 14199?
The form refers to "the enclosed letter," so it comes with an IRS letter that explains the requirements.
What is the worksheet mentioned on the form?
The worksheet for Recapture of COBRA Premium Assistance for Higher Income Taxpayers. The form says it is also included with the letter and is sent back when recapture does not apply because of the modified adjusted gross income calculation.
Where do I send Form 14199?
The form says to send it to the IRS ("send us") but prints no address. It refers to the letter enclosed with it.
Does Form 14199 have separate instructions?
No. The form points to the enclosed letter and Publication 502 for the requirements.