b'ACA PRE-PRINTED FORMSLaser & Pressure Seal1095-B __ __ PS1095B500 __560118Form1095-B Health Coverage VOID OMB No. 1545-2252PS1095B ____ Department of the Treasury Go to www.irs.gov/Form1095B for instructions and the latest information. CORRECTED 2022Internal Revenue Service Do not attach to your tax return. Keep for your records.Part I Responsible IndividualEmployer Name 1Name of responsible individualFirst name, middle name, last name 5City or town 2 Social security number (SSN) or other TIN 3 Date of birth (if SSN or other TIN is not available)Employer Address Line 1 4 Street address (including apartment no.) 6State or province 7Country and ZIP or foreign postal codeEmployer Address Line 2 1095-C Part II . 9Reserved 11 PS1095C500Employer Address Line 3 8 Enter letter identifying Origin of the Health Coverage (see instructions for codes): Information About Certain Employer-Sponsored Coverage (see instructions)10Employer name12 Street address (including room or suite no.) 13City or town 14State or province 15Country and ZIP or foreign postal codePart IIIIssuer or Other Coverage Provider (see instructions) 1095-C Employer-Provided Health Insurance Offer and CoverageVOID 6001201095-BCBLK 16Name (a) Name of covered individual(s) (b) SSN or other TIN 20City or townCovered1718Contact telephone numberFormEmployee Do not attach to your tax return. Keep for your records. CORRECTED OMB No. 1545-225119 Street address (including room or suite no.) 21State or province 22Country and ZIP or foreign postal codeDepartment of the TreasuryGo to www.irs.gov/Form1095C for instructions and the latest information. 2022 PS1095CInternal Revenue Service2Social security number (SSN) Applicable Large Employer Member (Employer)Part I7Name of employer 8 Part IVCovered Individuals (Enter the information for each covered individual.) (e) Months of coverage 1Name of employee (first name, middle initial, last name)9Street address (including room or suite no.)10 Contact telephone number (c) DOB (if SSN or other (d)3Street address (including apartment no.) Policy Holder Name First name, middle initial, last name TIN is not available)all 12 monthsJanFebMarAprMayJunJulAugSep Oct NovDecPolicy Holder Address Line 1 4City or town 5State or province6 Country and ZIP or foreign postal code11 City or town 12State or province 13 Country and ZIP or foreign postal codePolicy Holder Address Line 2 23 Part IIEmployee Offer of Coverage Feb Mar Employees Age on January 1 July Plan Start Month (enter 2-digit number): Dec PS1095BC500BLKPolicy Holder Address Line 3 All 12 Months Jan Apr May June Aug Sept Oct NovFoldHere 2024 image not available24 14Offer of Coverage (enter required code)25 15Employee$ $ $ $ $ $ $ $ $ $ $ $ $RequiredPS1095BCBLKContribution (see instructions) 26 16 Section 4980H Safe Harbor and Other Relief (enter FoldHere at time of printing.code, if applicable)2024 image not available27560115 Part III If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.Form1095-B Health Coverage VOID OMB No. 1545-2252 This panel 28 17 ZIP CodeCovered Individuals(b) SSN or other TIN(c) TIN is not available)all 12 monthsJan Feb Mar Apr May (e) Months of coverageAug Sept Oct Nov Dec560118Form1095-B Health Coverage CORRECTED OMB No. 1545-2252 29 First name, middle initial, last name DOB (if SSN or other (d) Covered JuneJulyInternal Revenue Service Do not attach to your tax return. Keep for your records CORRECTED 202022 Contains 30 18Department of the Treasury Information about Form 1095-B and its separate instructions is at www.irs.gov/form1095b. 20 (a) Name of covered individual(s)VOIDDepartment of the Treasury Go to www.irs.gov/Form1095B for instructions and the latest information 2 Social security number (SSN)Part I Responsible Individual (Policy Holder)at time of printing.Internal Revenue ServicePart I Name of responsible individual, street address, city or town, state or province, country, and ZIP or foreign postal code 2 Social security number (SSN) or other TIN 3Date of birth (if SSN or other TIN is not available) 1095 Copy B Backer 1911Name of responsible individualFirst name, middle name, last name 3 Date of birth (If SSN is not available)Responsible Individual4 Street address (including apartment no.) 5City or town 6State or province 7Country and ZIP or foreign postal code VOID 600120 Information 31 2092024 image not available9Reserved8 8 Enter letter identifying Origin of the Health Coverage (see instructions for codes): 32Enter letter identifying Origin of the Policy (see instructions for codes): Part II Information About Certain Employer-Sponsored Coverage14State or province 11 . CORRECTED OMB No. 1545-2251 33 21Part II Form1095-C Employer-Provided Health Insurance Offer and Coverage 10 Employer Sponsored Coverage (If Line 8 is A or B, complete this part.)(see instructions)10Employer name Department of the TreasuryDo not attach to your tax return. Keep for your recordsEmployer name, street address, city or town, state or province, country, and ZIP or foreign postal code12 Street address (including room or suite no.) Internal Revenue Service 13City or town Go to www.irs.gov/Form1095C for instructions and the latest information. 2022 22Part I Employee 2Social security number (SSN) 15Country and ZIP or foreign postal code834Applicable Large Employer Member (Employer)at time of printing.Part IIIIssuer or Other Coverage Provider (see instructions) 17 7Name of employer10 Contact telephone number 35 23Part IIIIssuer or Other Coverage Provider(first name, middle initial, last name) 18Contact telephone number1Name of employee1616NameName, street address, city or town, state or province, country, and ZIP or foreign postal code3Street address (including apartment no.) 20City or town 21State or province9Street address (including room or suite no.) 36 2419 Street address (including room or suite no.) 22Country and ZIP or foreign postal codePart IVCovered Individuals (Enter the information for each covered individual(s).)6 Country and ZIP or foreign postal code11 City or town 12State or province 13 Country and ZIP or foreign postal code4City or town 5State or provincePart IVCovered Individuals (Enter the information for each covered individual.)First name, middle initial, last name(b) SSN or other TINTIN is not available)Covered Employees Age on January 1 Plan Start Month (enter 2-digit number): Dec 37 25(a) Name of covered individual(s)Part II (b)Employee Offer of Coverage Feb JanMar Mar Apr May (e) Months of coverageAugAug SepNovNov Sept Oct Nov 38 26(a) Name of covered individual(s) SSN (c)(c) DOB (if SSN or otherall 12 months (e) Months of coverage(d) DOB (If SSN is notCovered 14Offer ofAll 12 Months available) Jan all 12 months FebApr JulJune SepJulyOctOct Aug DecDecMayJunCoverage (enter required code)2023 image not available2323 15Employee39 27Required Contribution (see$ $ $ $ $ $ $ $ $ $ $ $ $instructions) 2424 16 Section 4980H40 41-0852411 28 Form1095-B (2022)Safe Harbor and Other Relief (enterRAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 29code, if applicable)2525at time of printing.2626 17 ZIP CodeCovered IndividualsFROM: 30 41-0852411 Form 1095-C (2022)Part III If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee. RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.(a) Name of covered individual(s) DOB (if SSN or other (d) Covered (e) Months of coverage 2727 First name, middle initial, last name (b) SSN or other TIN (c) TIN is not available)all 12 monthsJan Feb Mar Apr May June July Aug Sept Oct Nov Dec 28For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1095B Form 1095-B(2015) This panel28RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.18 41-0852411 1095B Form 1095-B(2022)19 Contains Important Tax Document Enclosed First-Class Mail20 1095 Copy C Backer21 Information FROM:2223RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1095C Form1095-C(2022)14035 Important Tax Document Enclosed First-Class MailFROM:TFP 77771 or 77772Important Tax Document Enclosed First-Class MailEccentric ZFoldAPEX - Sheets per pack TFP - Forms per pack50s500s100s500sFORM DESCRIPTION1095-B HEALTH COVERAGE1095B501095B5001095B1095B5001095-B Employee/Employer Copy Health Coverage N1095B50N1095B500N1095BN1095B5001095-B Health Coverage Laser Cut Sheet - Alternate Format1095BIRS501095BIRS5001095BIRS1095BIRS5001095-B IRS Copy Health Coverage1094BT501094BT5001094BT1094BT5001094-B Transmittal Of Health Coverage Information Returns Transmittal For Form 1095-BN/APS1095B500N/APS1095B50014" Pressure Seal EZ-Fold 1095-B Employees Copy Health Coverage Bulk Pack N/AN/APSN1095BN/APressure Seal 1095-B Health Coverage Pressure Seal - Alternate Format1095-B CONTINUATION1095BC50#N/A1095BC#N/A1095-B Continuation Employee/Employer Copy Health Coverage 1095BIRSC50#N/A1095BIRSC#N/A1095-B IRS Continuation Copy Health Coverage 1095-C EMPLOYER PROVIDED HEALTH INSURANCE OFFER & COVERAGE1095C501095C500N/A1095C5001095-C Employee/Employer Copy Employer-Provided Health Insurance Offer And CoverageN1095C50N1095C500N1095CN1095C5001095-C Employer-Provided Health Insurance Offer and Coverage Laser Cut Sheet - Alternate Format1095CIRS50N/AN/A1095CIRS5001095-C IRS Copy Employer-Provided Health Insurance Offer And Coverage 1094CT501094CT5001094CT1094CT5001094-C Transmittal Of Employer-Provided Health Insurance Offer And CoverageInformation Returns For Form 1095C-3 Page FormN/APS1095C500#N/APS1095C50014" Pressure Seal EZ-Fold 1095-C Employees Copy Employer Health Insurance Offer And Coverage Bulk Pack1095-C CONTINUATION1095CC50N/A1095CC#N/AForm 1095-C Continuation Employee/Employer Copy Employer-Provided Health Insurance Offer And Coverage1095CIRSC50N/A1095CIRSC#N/AForm 1095-C IRS Continuation Copy Employer-Provided Health Insurance Offer And CoverageN/AN/APSN1095C#NAPressure Seal 1095-C Employer-Provided Health Insurance Offer and Coverage - Alternate Format1095-B OR C BLANK1095BCBLK501095BCBLK500#N/A1095BCBLK5001095-B And/Or 1095-C Blank W/Printed Backer InstructionsN/APS1095BC500BLK#N/APS1095BC500BLK14" Pressure Seal EZ-Fold 1095-B and/or 1095-C Blank w/Printed Backer Instructions Bulk Pack SOFTWARE & CD14035 2024 ACA Software Includes ACA Forms & Transmittals; Can Create, Print And E-File Forms Throughthe Software. Allows You To Output Data On The Pre-Printed Vertical Format Forms. 42'