b"ACA FORMSOrdering ACA FormsWHAT ARE THE AFFORDABLE CARE ACT (ACA) FORMS?Form Whats Reported? Who Issues? Submit to IRS? Recipient Copies?Which months the insured and Insurance carrier for employersInsurance carrier submits: Yes, by March 2 1095-B Health Coverage his or her family was coveredwith employer-sponsored groupFeb. 28 paper; Insurance carrier under the plan health plans March 31 electronic sends to recipientsThe months the insured and Self-insured employers with fewerFeb. 28 paper;1095-B Health Coverage their family were covered than 50 full-time employees whoMarch 31 electronic Yes, by March 2under the plan provide health plans1094-B Transmittal of HealthSummary transmittal record Accompanies 1095-B forms Feb. 28 paper; N/ACoverage Information Returns of 1095-Bs when mailed to IRS March 31 electronicEmployers with 50 or more1095-C Employer-ProvidedWhether or not the employerfull-time employees Feb. 28 paper;Health Insurance Offer andoffered health coverage to(Applicable Large Employers) March 31 electronic Yes, by March 2Coverage employees Both insured and self-insuredissue 1095-C1094-C Transmittal of Employer Provided Health InsuranceSummary transmittal record Accompanies 1095-Cs when Feb. 28 paper; N/AOffer and Coverage Informationof 1095-Cs mailed to IRS March 31 electronicReturns 1095-CIRSC Employer-ProvidedEmployers with 50 or moreHealth Insurance Offer andfull-time employees Feb. 28 paper;Coverage (Continuation Form)Additional covered individuals(Applicable Large Employers) March 31 electronic Yes, by March 2Both insured and self-insuredissue 1095-CIf any date shown falls on a Saturday, Sunday or legal holiday, the due date is the next business day.IRS REPORTING RECIPIENT REPORTINGOnly the official IRS landscape format can be submitted when reporting Employers provide the employee/recipient the approved portrait format. to the IRS. These are available in pre-printed or blank form version designed to accommodate envelope 77771 or DWMR. We recommend you review EMPLOYER FILE COPY AND REPORTING software compatibility.Employers must file with the IRS using the landscape format only. They areIRS LANDSCAPE FORMAT IS NOW TWO PAGESalso required to keep a copy on file and provide a copy to the recipient for their records. Please note that Form 1095-C (IRS landscape format) is now two pages.Part III, which lists self-insured coverage for employees and dependents, has 1095-CIRS moved to page 3 (instructions are on page 2). Due to this IRS requirement, Form1095-C Employer-Provided Health Insurance Offer and CoverageVOID 600120employers must purchase an additional Form 1095-CIRSC if dependents need OMB No. 1545-2251Department of the TreasuryDo not attach to your tax return. Keep for your records. CORRECTED 2022Internal Revenue Service Go to www.irs.gov/Form1095C for instructions and the latest information.81095-CIRSCto be reported. Part I Employee 2Social security number (SSN) Applicable Large Employer Member (Employer)1Name of employee (first name, middle initial, last name)7Name of employer 2024 image not available3Street address (including apartment no.) 9Street address (including room or suite no.)10 Contact telephone number4City or town 5State or province6 Country and ZIP or foreign postal code11 City or town 12State or province Form 1095-C (2021) 600320313 Country and ZIP or foreign postal code Page Part II Employee Offer of Coverage Feb Mar Employees Age on January 1 July Plan Start Month Part IIICovered Individuals(b) SSN or other TIN (c) TIN is not available)all 12 monthsJan Feb Mar Apr May (e) Months of coverage Aug Sept Oct Nov Dec14Offer ofAll 12 Months Jan Apr May June Aug Sept(enter 2-digit number):If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.Coverage (enterOct Nov Dec DOB (if SSN or other (d) Covered June July 1094-CTat time of printing.(a) Name of covered individual(s)required code) First name, middle initial, last name15Employee Required Contribution (see$ $ $ $ $ $ $ $ $ $ $ 18 $ $instructions) 16 Section 4980H 2024 image not availableOther Relief (enter19 Form 1094-C Transmittal of Employer-Provided Health Insurance Offer and CORRECTED 120118 1095-BIRSSafe Harbor and code, if applicable)OMB No. 1545-225117 ZIP Code41-0852411 20 Form1095-C(2022) Department of the Treasury Coverage Information Returns 2022RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 1095CIRS Internal Revenue Service Go to www.irs.gov/Form1094C for instructions and the latest information.at time of printing.21 Part I Applicable Large Employer Member (ALE Member) 2 1 Name of ALE Member (Employer) 22 3 Street address (including room or suite no.) 5601182024 image not available23 4 City or town 5 State or province 6 Country and ZIP or foreign postal code Form1095-B Health Coverage VOID OMB No. 1545-225224 7 Name of person to contact 8 Contact telephone number Department of the Treasury Do not attach to your tax return. Keep for your records CORRECTED 2022 1094-BTInternal Revenue Service Go to www.irs.gov/Form1095B for instructions and the latest information9 Name of Designated Government Entity (only if applicable)10Part I Responsible Individual 2 Social security number (SSN) or other TIN 3 Date of birth (if SSN or other TIN is not available)1Name of responsible individualFirst name, middle name, last nameat time of printing.25 11Street address (including room or suite no.) 4 Street address (including apartment no.) 5City or town 6State or province 7Country and ZIP or foreign postal codeFor Ofcial Use Only2024 image not available12City or town 13 State or province 14 Country and ZIP or foreign postal code 9Reserved 11011626 15Name of person to contact16 Contact telephone number 8 Enter letter identifying Origin of the Health Coverage (see instructions for codes): . 11 FormOMB No. 1545-225227 17Reserved Part II . Information About Certain Employer-Sponsored Coverage (see instructions) 1094-B Transmittal of Health Coverage Information Returns202210Employer name15Department of the TreasuryEmployer identi\x1fcation number (EIN)12 Street address (including room or suite no.) 13City or town 14State or province Internal Revenue Service Go to www.irs.gov/Form1094B for instructions and the latest information. 2at time of printing.Country and ZIP or foreign postal code28 18Total number of Forms 1095-C submitted with this transmittal .1 Filer's name19Is this the authoritative transmittal for this ALE Member? If Yes, check the box and continue. If No, see instructions . Part III . Issuer or Other Coverage Provider (see instructions) 1718Contact telephone number 4 Contact telephone number16Name 3 Name of person to contact29 Part II ALE Member Information 19 Street address (including room or suite no.) 20City or town 21State or province 22Country and ZIP or foreign postal code2024 image not available30 41-0852411 1095CIRSC 20 Form1095-C(2021) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Part IV . . .(a)Covered Individuals. . . . . (Enter the information for each covered individual.) 5 Street address (including room or suite no.) 6 City or town For Ofcial Use OnlyRAA #1607 21Is ALE Member a member of an Aggregated ALE Group? . First name, middle initial, last name No(b) SSN or other TINTIN is not available)Covered(e) Months of coverage 8 Country and ZIP or foreign postal codeYes (d) Name of covered individual(s)(c) DOB (if SSN or otherall 12 months7 State or provinceIf No, do not complete Part IV.Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec22Certications of Eligibility (select all that apply):at time of printing.23A. Qualifying Offer Method B. Reserved C. Reserved D. 98% Offer Method 9Total number of Forms 1095-B submitted with this transmittal Under penalties of perjury, I declare that I have examined this return and accompanying documents, and to the best of my knowledge and belief, they are true, correct, and complete. 24 Under penalties of perjury, I declare that I have examined this return and accompanying documents, and to the best of my knowledge and belief, they are true, correct, and complete.SignatureTitle Date25RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1094CT Form1094-C(2022) SignatureTitle Date26 RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1094BT Form 1094-B(2022)2728RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1095BIRS Form1095-B(2022)41"