case 7:15-cv-00151-o document 96 filed 05/21/18 page 1 of 49 … · 2018. 9. 25. · address...
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Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 1 of 49 PageID 4237
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Fann 843 Claim for Refund and Request for Abatement (Rev. August 2011) Department of the Treasury Internal Revenue Service
► See separate instructions.0MB No. 1545-0024
Use Form 843 if your claim or request involves: (a) a refund of one of the taxes (other than income taxes or an employer's claim for FICA tax, RRTA tax, or income tax
withholding) or a fee, shown on line 3,(b) an abatement of FUTA tax or certain excise taxes, or(c) a refund or abatement of interest, penalties, or additions to tax for one of the reasons shown on line 5a.
Do not use Form 843 if your claim or request involves: (a) an overpayment of income taxes or an employer's claim for FICA tax, RRTA tax, or income tax withholding (use the
appropriate amended tax return),(b)
(c)
a refund of excise taxes based on the nontaxable use or sale of fuels, oran overpayment of excise taxes reported on Form(s) 11-C, 720, 730, or 2290.
Name(s) Your social security number Texas Health and Human Services Commission
Address (number, street, and room or suite no.) 4900 N. Lamar Blvd.
Spouse's social security number
City or town, state, and ZIP code Austin, TX 78751
Employer identification number (EIN) 742638006
Name and address shown on return if different from above Daytime telephone number
1
3
4
512-487-3355Period. Prepare a separate Form 843 for each tax period or fee year. ( F� vr d)o I f'1) 2 Amount to be refunded or abated: From January 1, 2015 to December),, 2015 $ $111,143,391.00 Type of tax or fee. Indicate the type of tax or fee to be refunded or abated or to which the interest, penalty, or addition to tax is related. D Employment D Estate D Gift D Excise D Income 0 Fee Type of penalty. If the claim or request Involves a penalty, enter the Internal Revenue Code section on which the penalty is based (see instructions). IRC section:
5a Interest, penalties, and additions to tax. Check the box that indicates your reason for the request for refund or abatement. (If none apply, go to line 6.)
Interest was assessed as a result of IRS errors or delays. A penalty or addition to tax was the result of erroneous written advice from the IRS.
□
□
□ Reasonable cause or other reason allowed under the law (other than erroneous written advice) can be shown for notassessing a penalty or addition to tax.
b Date(s) of payment(s) ► ---------------------------------
6 Original return. Indicate the type of fee or return, if any, filed to which the tax, interest, penalty, or addition to tax relates. 0 706 0 709 0 940 0 941 0 943 0 945 D 990-PF D 1040 D 1120 D 4720 D Other (specify)► ACA Sec. 9010 Fee
7 Explanation. Explain why you believe this claim or request should be allowed and show the computation of the amount shown on line 2. If you need more space, attach additional sheets.
The Health Insurance Provider's Fee under the Affordable Care Act as applied to the States through their Medicaid and CHIP managed care organizations is an unconstitutional tax on a sovereign, is unconstitutionally coercive, and is an unconstitutional delegation to a private entity.
Signature. If you are filing Form 843 to request a refund or abatement relating to a joint return, both you and your spouse must sign the claim. Claims filed by corporations must be signed by a corporate officer authorized to sign, and the officer's title must be shown. Under penalties of perjury, I declare that I have examined this claim, including accompanying schedules and statements, and, to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) Is based on all Information of which preparer has any knowledge.
(J¥.tl.11 a llcable. c1aiii,;J�f�1�/dfi�c��-j-�d_i_oai{!laLj-//, __ gl?/�--
-�/.--�-�4N/!__�JaUJ-�Ld� ------------------------------------·Signature (spouse, ii joint return) Date
Paid PrinVType preparer's name I Preparer's signature I Date I Check D II I PTIN
Preparerself-employed
Use Only Firm's name ► I Finn's EIN ►
Firm's address ► I Phone no. For Privacy Act and Paperwork Reduc ion Act Notice, see separate instructions. Cat. No. 10180R Fann 843 (Rev. 8-2011) Texas Exhibit D A1187
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Form 843(Rev. August 2011) Department of the Treasury Internal Revenue Service
Claim for Refund and Request for Abatement
► See separate instructions.
Use Form 843 if your claim or request involves:
0MB No. 1545-0024
(a) a refund of one of the taxes (other than income taxes or an employer's claim for FICA tax, RRTA tax, or income taxwithholding) or a fee, shown on line 3,
(b) an abatement of FUTA tax or certain excise taxes, or (c) a refund or abatement of interest, penalties, or additions to tax for one of the reasons shown on line Sa.
Do not use Form 843 if your claim or request involves: (a) an overpayment of income taxes or an employer's claim for FICA tax, RRTA tax, or income tax withholding (use the
appropriate amended tax return), (b) a refund of excise taxes based on the nontaxable use or sale of fuels, or (c) an overpayment of excise taxes reported on Form(s) 11 C, 720, 730, or 2290.
NatT1e(s) Your social security number Nebraska Department of Health and Human Services
Address (number, street, and room or suite no.) 301 Centennial Mall South
Clty or town, state, and ZIP code Lincoln, NE 68508
Name and address shown on return if dit(erent from above
Spouse's social security number
Employer Identification number (EIN) 47-0491233
Daytime lelephone number
1 Period, Prepare a separate Form 843 for each tax period or fee year. (�e.. yu� to �) 2 Amount to be refunded or abated: From January 1, 2014 to December 31, 2014 $ 12,075,744
3 Type of tax or fee, Indicate the type of tax or fee to be refunded or abated or to which the interest, penalty, or addition to tax is related. D Employment D Estate D Gift D Excise D Income 0 Fee
4 Type of penalty. If the claim or request involves a penalty, enter the Internal Revenue Code section on which the penalty is based (see instructions). IRC section:
5a Interest, penalties, and additions to tax. Check the box that indicates your reason for the request for refund or abatement. (If none apply, go to line 6.) D Interest was assessed as a result of IRS errors or delays. 0 A penalty or addition to tax was the result of erroneous written advice from the IRS. O Reasonable cause or other reason allowed under the law (other than erroneous written advice) can be shown for not
assessing a penalty or addition to tax, b Date(s) of payment(s) ►
6 Original return. Indicate the type of fee or return, if any, filed to which the tax, interest, penalty, or addition to tax relates. D 706 D 109 □ 940 D 941 D 943 D 945 D 990-PF D 1040 D 1120 D 4720 0 Other(specify)► ACAsec.9010fee
7 Explanation. Explaln why you believe this claim or request should be allowed and show the computation of the amount shown on line 2. If you need more space, attach additional sheets.
The Health Insurance Provider's Fee under the Affordable Care Act as applied to the States through their Medicaid and CHIP Managed Care Organizations is an unconstitutional tax on a sovereign, is unconstitutionally coercive, and is an unconstitutional delegation to a private entity.
Signature. If you are filing Form 843 to request a refund or abatement relating to a joint return, both you and your spouse must sign the claim. Claims filed by corporations must be signed by a corporate officer authorized to sign, and the officer's title must be shown. Under pe�sll]es of perjury, I declaro th&! I have eKamlnad !his clnlm, Including occompa,,ylng schedutos and stntements, and, to the best of my knowledge and belief, it Is!rue. correct. ar,d corpptete. Oedaratlon of preparer (other 1han laapayerJ is based 011 all Informs on of which preparer has any knowledge.
m.;.,"fi�.g#�� ·.i.tft_.�/ -&i'.'/Yl e..A �:_�r {)µ'-�l'A. __________________ ,_�/1'-1 / U/J-Slgnature [Tlllo, II appllcablo. Cl.\lms by corporations must btligned by an otflcer.} (/ Cr- Date
Signature (spouse, if joint return) · Date
·
Paid Print/Type preparer's name I Preparer's signature I Date I Check D if I PTIN
Preparer t------,---- - ��- - ----- --------,--�se_11_-e_m_p_1_oy_e_d_,__ _____ _ Use Only t-Fi_rm_'_s_n_an_,e __ ► _____________________________ I-IF_i_rm_'_s_E_IN_► __ _____ _
Firm's address ► I Phone no. For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 101 BOR Forrn 843 (Rev. 8 2011)
Nebraska Exhibit B A1194
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 17 of 49 PageID 4253
Form 843 (Rev. August 2011)
Department of the Treasury Internal Revenue Service
Clalm for Refund and Request for Abatement
► See separate instructions.
Use Form 843 if your claim or request involves:
OM B No. 154 50024
(a) a refund of one of the taxes (other than income taxes or an employer's claim for FICA tax, RRTA tax, or income taxwithholding) or a fee, shown on line 3,
(b) an abatement of FUTA tax or certain excise taxes, or (c) a refund or abatement of interest, penalties, or additions to tax for one of the reasons shown on line 5a.
Do not use Form 843 if your claim or request involves: (a) an overpayment of income taxes or an employer's claim for FICA tax, RRTA tax, or income tax withholding (use the
appropriate amended tax return),
(bl a refund of excise taxes based on the nontaxable use or sale of fuels, or (c) an overpayment of excise taxes reported on Form(s) 11-C, 720, 730, or 2290.
Name(s) Your social security number
Nebraska Oepartmenl of Health and Human Services Address (number, street, and room or suite no.)
301 Centennial Mall South City or town, state, and ZIP code Lincoln, NE 68508
Name and address shown on return if different from above
Spouse's social securily number
Employer Identification number (EIN) 47-0491233
Daytime telephone number
Period. Prepare a separate Form 843 for each tax period or fee year. /� l(b<.r t-':tl:J) 2 Amount to be refunded or abated: From January 1, 2015 to December 31, 2015 $ 11,725,067
3 Type of tax or fee. Indicate the type of tax or fee to be refunded or abated or to which the interest, penalty, or addition to tax is related. D Employment D Estate O Gift D Excise O Income 0 Fee
4 Type of penalty. If the claim or request involves a penalty, enter the Internal Revenue Code section on which the penalty is based (see instructions). IRC section:
5a Interest, penalties, and additions to tax. Check the box that Indicates your reason for the request for refund or abatement. (If none apply, go to line 6.) D Interest was assessed as a result of IRS errors or delays. D A penalty or addition to tax was the result of erroneous written advice from the IRS. D Reasonable cause or other reason allowed under the law (other than erroneous written advice) can be shown for not
assessing a penalty or addition to tax. b Date(s) of payment(s) ►
6 Original return. Indicate the type of fee or return, if any, filed to which the tax, interest, penalty, or addition to tax relates. D 706 D 709 D 940 D 941 D 943 D 945 D 990-PF D 1040 D 1120 D 4 720 0 Other (specify)► ACA sec, 9010 fee
7 Explanation. Explain why you believe this claim or request should be allowed and show the computation of the amount shown on line 2. If you need more space, attach additional sheets.
The Health Insurance Provid11r's Fee under the Affordable Care Act as applied to the States through their Medicaid and CHIP Managed Care Organizations is an unconstitutional tax on a sovereign, is unconstitutionally coercive, and is an unconstitutional delegation to a private entity.
Signature. If you are filing Form 843 to request a refund or abatement relating to a joint return, both you and your spouse must sign the claim. Claims filed by corporations must be signed by a corporate officer authorized to sign, and the officer's title must be shown. Under penal ties of perjury. I declare that I have examined this claim, including accompanying schedules a nd sta tements, and. to the best of my knowledge and belief, it is true, correct, and compl<>te. Declaration ot p rep arer (other than taxpayer) is base d on all lnfom,ation of which prep arer has any knowledge.
���<A-�?:...1 t/� __ £ne,.-.1 a tjt_(' _ V,/r-l''J: <-<c L______________ ·-·--5/_l'·f/µc-6._ ...Signature (TIiie, if applicable. Claim& by corporations must bes!�d by an officer.) '{/t-
"'
Date
Signature (spouse, it joint return) ·
Date ·
Paid Print/Type preparer's name I Preparer's signature I Date I Check D if I PTIN
Preparer l -------- ---�--- -----------'-----..--,__se_11_e_m_p_1o_y_e_d,__I _ __ _ Use Only f-F_i_,m_·_s_na_m_e _. _► _____________________________ lf-F_i_rm_'_s_E_IN_► _______ _
Firm's address ► I Phone no.
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 101 SOR Form 843 (Rev. 8-2011)
Nebraska Exhibit C A1195
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 18 of 49 PageID 4254
A1196
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 19 of 49 PageID 4255
A1197
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 20 of 49 PageID 4256
A1198
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Wisconsin Exhibit A
A1199
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 22 of 49 PageID 4258
Wisconsin Exhibit B
A1200
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 23 of 49 PageID 4259
Wisconsin Exhibit C
A1201
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A1202
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 25 of 49 PageID 4261
A1203
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A1204
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A1205
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A1206
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A1207
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A1208
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 31 of 49 PageID 4267
Louisiana Exhibit A
A1209
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 32 of 49 PageID 4268
A1210
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 33 of 49 PageID 4269
Louisiana Exhibit B
A1211
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 34 of 49 PageID 4270
Louisiana Exhibit C
A1212
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 35 of 49 PageID 4271
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 36 of 49 PageID 4272
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 37 of 49 PageID 4273
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 38 of 49 PageID 4274
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Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 40 of 49 PageID 4276
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 41 of 49 PageID 4277
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 42 of 49 PageID 4278
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 43 of 49 PageID 4279
A1221
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 44 of 49 PageID 4280
A1222
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 45 of 49 PageID 4281
A1223
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A1224
Case 7:15-cv-00151-O Document 96 Filed 05/21/18 Page 47 of 49 PageID 4283
A1225
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A1226
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