Form 1095-B
2025
Department of the Treasury  
Internal Revenue Service
Health Coverage
 Do not attach to your tax return. Keep for your records.
Go to www.irs.gov/Form1095B for instructions and the latest information.
OMB No. 1545-2252
560118
VOID
CORRECTED
Part I
  Responsible Individual
1    Name of responsible individual–First name, middle name, last name
2   Social security number (SSN) or other TIN
3   Date of birth (if SSN or other TIN is not available)
4   Street address (including apartment no.)
5    City or town
6    State or province
7    Country and ZIP or foreign postal code
8   Enter letter identifying Origin of the Health Coverage (see instructions for codes): 
.
.
.
9    Reserved
Part II
  Information About Certain Employer-Sponsored Coverage (see instructions)
10    Employer name
11    
12   Street address (including room or suite no.)
13    City or town
14    State or province
15    Country and ZIP or foreign postal code
Part III
  Issuer or Other Coverage Provider (see instructions)
16    Name
17 
18    Contact telephone number
19   Street address (including room or suite no.)
20    City or town
21    State or province
22    Country and ZIP or foreign postal code
Part IV
  Covered Individuals (Enter the information for each covered individual.)
(a) Name of covered individual(s) 
First name, middle initial, last name
(b) SSN or other TIN
(c) DOB (if SSN or other 
TIN is not available)
(d) Covered 
all 12 months
(e) Months of coverage
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
      
      
    
    
    
     
   
23
24
Here
600320
Form 1095-C (2025 )
Page 3
Part III
Covered Individuals 
If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.
(a) Name of covered individual(s) 
First name, middle initial, last name
(b) SSN or other TIN
(c) DOB (if SSN or other 
TIN is not available)
(d) Covered 
all 12 months
(e) Months of coverage 
     
     
     
     
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
18
19
20
21
22
23
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7171
VOID
$
$ 
$ 
$
$
$
$
$
$
Form 1099-NEC
(Rev. December 2026)
Nonemployee 
Compensation
Copy A
For
Internal Revenue 
Service Center
OMB No. 1545-0116
information, 
Privacy Act, and 
Paperwork 
Reduction Act 
Notice, see the 
General 
Instructions for 
Certain 
Information 
Returns.
www.irs.gov/Form1099
For calendar year
CORRECTED
PAYER’S name
Street address
Room or suite no.
City or town
Telephone number
State or province
Country
ZIP or foreign postal code
PAYER’S TIN
RECIPIENT’S TIN
RECIPIENT’S name
Street address
Apt. no.
City or town
State or province
Country
ZIP or foreign postal code
Account number (see instructions)
2nd TIN not.
1a Nonemployee compensation
1b Cash tips
1c TTOC
1d Overtime compensation
2   Payer made direct sales totaling $5,000 or more of 
consumer products to recipient for resale
3   Excess golden parachute payments
4   Federal income tax withheld
5   State tax withheld
6   State/Payer’s state no.
7   State income
RECIPIENT COPIES
Form 1099-R
CORRECTED (if checked)
OMB No. 1545-0119
1
Gross distribution
2a Taxable amount
2b Taxable amount
Total
not determined
distribution
3 Capital gain (included
4 Federalincome tax withheld
5
in box 2a)
6 Net unrealized appreciation
7
8 Other
in employer’ssecurities
Distributions From Pensions, 
Annuities, Retirement or 
Profit-Sharing Plans, IRAs, 
Insurance Contracts, etc.
Distributions From Pensions, 
Annuities, Retirement or 
Profit-Sharing Plans, IRAs, 
Insurance Contracts, etc.
IRA/
SEP/
SIMPLE
Distributioncode(s)
2025
Employee contributions/Designated
 Roth contributionsor insurance premiums
$
$
$
$
$
Form 1099-R
CORRECTED (if checked)
OMB No. 1545-0119
1
Gross distribution
2a Taxable amount
2b Taxable amount
Total
not determined
distribution
3 Capital gain (included
4 Federalincome tax withheld
5
in box 2a)
6 Net unrealized appreciation
7
8 Other
in employer’ssecurities
IRA/
SEP/
SIMPLE
Distributioncode(s)
2025
Employee contributions/Designated
 Roth contributionsor insurance premiums
$
$
$
$
$
PAYER’S TIN
RECIPIENT’S TIN
PAYER’S TIN
RECIPIENT’S TIN
PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and phone no.
PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and phone no.
requirement
Date of payment
13
12
requirement
Date of payment
13
12
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1099 | Pages 4-7
Streamline your tax reporting with 1099 forms
a Employee's soc. sec. no.
1 Wages, tips, other comp.
2 Federal income tax withheld
3 Social security wages
4 Social security tax withheld
b Employer ID number (EIN)
5 Medicare wages and tips
6 Medicare tax withheld
c Employer's name, address, and ZIP code
d Control number
e Employee's name, address, and ZIP code
7 Social security tips
8 Allocated tips
9
10
11
12a
13
12b
12c
12d
15 State Employer's state ID number
18 Local wages, tips, etc.
19 Local income tax
20 Locality name
Code  See inst. for box 12
Statutory employee
Retirement plan
Third-party sick pay
Code
Code
Code
Other
14a
State income tax
17
State wages, tips, etc.
16
OMB No. 1545-0029
 41-0852411
Suff.
 plans
14b Treasury Tipped Occupation Code(s)
a Employee's soc. sec. no.
1 Wages, tips, other comp.
2 Federal income tax withheld
3 Social security wages
4 Social security tax withheld
b Employer ID number (EIN)
5 Medicare wages and tips
6 Medicare tax withheld
c Employer's name, address, and ZIP code
d Control number
e Employee's name, address, and ZIP code
7 Social security tips
8 Allocated tips
9
10
11
12a
13
12b
12c
12d
15 State Employer's state ID number
18 Local wages, tips, etc.
19 Local income tax
20 Locality name
Code
Statutory employee
Retirement plan
Third-party sick pay
Code
Code
Code
State income tax
17
State wages, tips, etc.
16
OMB No. 1545-0029
 41-0852411
Suff.
plans
Other
14a
14b Treasury Tipped Occupation Code(s)
Copy B—To Be Filed With Employee's
FEDERAL Tax Return.
Copy 2—To Be Filed With Employee's State,
City, or Local Income Tax Return.
MW285
1
1
Wages, tips, other compensation
Wages, tips, other compensation
3
3
Social security wages
Social security wages
5
5
Medicare wages and tips
Medicare wages and tips
2
2
Federal income tax withheld
Federal income tax withheld
4
4
Social security tax withheld
Social security tax withheld
6
6
Medicare tax withheld
Medicare tax withheld
c
c
Employer’s name, address, and ZIP code
Employer’s name, address, and ZIP code
OMB No. 1545-0029
OMB No. 1545-0029
7
7
Social security tips
Social security tips
8
8
Allocated tips
Allocated tips
10
10
Dependent care benefits
Dependent care benefits
11
11
Nonqualified plans
Nonqualified plans
12a
12a
b
b
Employer identification number (EIN)
Employer identification number (EIN)
a
a
Employee’s social security number
Employee’s social security number
13
13
14
14
Other
Other
1A
Department of the Treasury
Department of the Treasury
—
—
Internal
Internal
Revenue Service
Revenue Service
S2001
8510027743
12b
12b
12c
12c
12d
12d
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Statutory
Statutory
employee
employee
Retirement
Retirement
plan
plan
Third-party
Third-party
sick pay
sick pay
A
9
9
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