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 employers withInsurance carrier submits: Yes, by March 2 1095-B Health Coverage his or her family was covered underemployer-sponsored group healthFeb. 28 paper; Insurance carrier the plan 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-Provided HealthWhether or not the employerfull-time employees Feb. 28 paper;Insurance Offer and Coverage offered health coverage to(Applicable Large Employers March 31 electronic Yes, by March 2employees Both insured and self-insuredissue 1095-C)1094-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-C)If 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 whenEmployers provide the employee/recipient the approved portrait reporting to the IRS. format. These are available in pre-printed or blank form version designed to accommodate envelope 77771. We recommend youEMPLOYER FILE COPY AND REPORTING review software compatibility.Employers must file with the IRS using the landscape format only.IRS LANDSCAPE FORMAT IS NOW TWO PAGESThey are also 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 moved to page 3 (instructions are on page 2). Due to this IRS 1095CIRS50 requirement, employers must purchase an additional Form 1095-CIRSC if dependents need to be reported. 600120 Form1095-C Employer-Provided Health Insurance Offer and CoverageVOID OMB No. 1545-2251 1095CIRSC50 Department of the TreasuryGo to www.irs.gov/Form1095C for instructions and the latest information CORRECTED 2024Internal Revenue Service Do not attach to your tax return. Keep for your recordsPart I Employee 2Social security number (SSN) Applicable Large Employer Member (Employer)1Name of employee (first name, middle initial, last name)7Name of employer 8 3Street 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 13 Country and ZIP or foreign postal code Form 1095-C ( Covered Individuals60032032024) Page Part IIEmployee Offer of Coverage Feb Mar Employees Age on January 1 July Plan Start Month (enter 2-digit number): Dec Part III If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee. Oct Nov Dec 1094CT50First name, middle initial, last name (b) SSN or other TIN (c) TIN is not available) (d) Covered(e) Months of coverage (a) Name of covered individual(s) DOB (if SSN or other 14Offer ofAll 12 Months Jan Apr May June Aug Sept Oct Nov all 12 monthsJan Feb Mar Apr May June July Aug SeptCoverage (enter required code) 18 12011815Employee Required Contribution (see$ $ $ $ $ $ $ $ $ $ $ $ $ 19 Form OMB No. 1545-2251instructions) 16 Section 4980H1094-C Transmittal of Employer-Provided Health Insurance Offer and CORRECTEDOther Relief (enter20 Department of the Treasury Coverage Information Returns 22024 1094BT50Safe Harbor and code, if applicable) Internal Revenue Service Go to www.irs.gov/Form1094C for instructions and the latest information.Part I Applicable Large Employer Member (ALE Member)17 ZIP Code41-0852411 1095CIRS Form1095-C(2024) 21 1 Name of ALE Member (Employer) RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 22 3 Street address (including room or suite no.) 5 State or province 6 Country and ZIP or foreign postal code 1101164 City or town OMB No. 1545-225223 7 Name of person to contact 8 Contact telephone number Form1094-B Transmittal of Health Coverage Information Returns 9 Name of Designated Government Entity (only if applicable)10Department of the TreasuryGo to www.irs.gov/Form1094B for instructions and the latest information. 2 20242025 image not available 24 11Street address (including room or suite no.) 13 State or province 14 Country and ZIP or foreign postal code For Ofcial Use Only Internal Revenue Service 4 Contact telephone number1 Filer's name12City or town 3 Name of person to contactat time of printing. 25 15Name of person to contact. 16 Contact telephone number . 5 Street address (including room or suite no.) 6 City or town For Ofcial Use Only2617Reserved . 7 State or province 8 Country and ZIP or foreign postal code27 2025 image not available 18Total number of Forms 1095-C submitted with this transmittal . . . . . . . . . . . . . . . . . . . 9Total number of Forms 1095-B submitted with this transmittal 28 19Is this the authoritative transmittal for this ALE Member? If Yes, check the box and continue. If No, see instructions Part II ALE Member Information29 at time of printing. 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 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.30 41-0852411 1095CIRSC Form 1095-C(2024) 21Is ALE Member a member of an Aggregated ALE Group?SignatureTitle DateRAA #1607 If No, do not complete Part IV. B.Reserved 2025 image not available RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1094BT Form 1094-B(2024)22Certications of Eligibility (select all that apply):A.Qualifying Offer Method Title at time of D.printing.C.Reserved 98% Offer MethodUnder 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. RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 Date Form1094-C(2024) 2025 image not availableSignature 1094CTat time of printing.33"