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 recordsPart 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 8 Enter letter identifying Origin of the Health Coverage (see instructions for codes): . 9ReservedEmployer Address Line 3 Part IIInformation About Certain Employer-Sponsored Coverage (see instructions) 111095-C 10Employer name 13City or town 14State or province 15Country and ZIP or foreign postal code12 Street address (including room or suite no.) 1718Contact telephone number PS1095C500Part IIIIssuer or Other Coverage Provider (see instructions)16Name19 Street address (including room or suite no.) 20City or town 21State or province 22Country and ZIP or foreign postal codeDo not attach to your tax return. Keep for your records VOID OMB No. 1545-2251Part IVCovered Individuals (Enter the information for each covered individual.) Form1095-C Employer-Provided Health Insurance Offer and CoverageCORRECTED 600120Policy Holder Name First name, middle initial, last name(b) SSN or other TINTIN is not available)CoveredJanFebMarApr Department of the TreasuryAugSepOct NovDec for instructions and the latest information82022 PS1095C(a) Name of covered individual(s)(c) DOB (if SSN or otherall 12 months Internal Revenue Service Go to www.irs.gov/Form1095CApplicable Large Employer Member (Employer) (d) (e) Months of coveragePart IJun Jul2Social security number (SSN)7Name of employer May Employee Policy Holder Address Line 1 Name of employee (first name, middle initial, last name)Policy Holder Address Line 2 23 31Street address (including apartment no.) 9Street address (including room or suite no.)10 Contact telephone numberPolicy Holder Address Line 324 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 codePart IIEmployee Offer of Coverage Feb Mar Employees Age on January 1 July Plan Start Month (enter 2-digit number): Dec25 14Offer ofAll 12 Months Jan Apr May June Aug Sept Oct Nov PS1095BC500BLKCoverage (enter required code)26 15Employee Required Contribution (see$ $ $ $ $ $ $ $ $ $ $ $ $instructions) 27 16 Section 4980H Safe Harbor and Form1095-B Health Coverage VOID OMB No. 1545-2252 17 ZIP CodeCovered IndividualsPS1095BCBLK560115 Other Relief (enter VOID 560118 28 code, if applicable)Form1095-B Health Coverage CORRECTED OMB No. 1545-2252 29 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 DecInternal Revenue Service Do not attach to your tax return. Keep for your recordswww.irs.gov/form1095b. CORRECTED 202022 30 (a) Name of covered individual(s)(b) SSN or other TIN(c) TIN is not available) (d) Covered Jan Feb Mar Apr May (e) Months of coverage Aug SeptFoldHere Department of the Treasury Information about Form 1095-B and its separate instructions is at20Department of the Treasury Go to www.irs.gov/Form1095B for instructions and the latest information 2 Social security number (SSN) First name, middle initial, last name DOB (if SSN or otherall 12 months JuneJulyPart I Responsible Individual (Policy Holder)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 3 Date of birth (if SSN or other TIN is not available) 1095-BCBLK 31 1811Name of responsible individualFirst name, middle name, last name 3 Responsible Individual4 Street address (including apartment no.) 5City or town 6State or province 7Date of birth (If SSN is not available)9 Country and ZIP or foreign postal code9Reserved8 8 Enter letter identifying Origin of the Health Coverage (see instructions for codes): 32 19Enter letter identifying Origin of the Policy (see instructions for codes): Part II Information About Certain Employer-Sponsored Coverage11 VOID 600120 33 20Part II Employer Sponsored Coverage (If Line 8 is A or B, complete this part.)(see instructions)10Employer name10Employer name, street address, city or town, state or province, country, and ZIP or foreign postal code12 Street address (including room or suite no.) Form1095-C Employer-Provided Health Insurance Offer and CoverageCORRECTED OMB No. 1545-2251 34 21Part IIIIssuer or Other Coverage Provider13City or townDepartment of the Treasury14State or province 15Country and ZIP or foreign postal code Applicable Large Employer Member (Employer) 2022Part IIIIssuer or Other Coverage Provider(see instructions) Internal Revenue Service 17Go to www.irs.gov/Form1095C for instructions and the latest information835 22Do not attach to your tax return. Keep for your recordsFoldHerePart I(first name, middle initial, last name) 18Contact telephone number1616NameName, street address, city or town, state or province, country, and ZIP or foreign postal code Employee 2Social security number (SSN)7Name of employer 1Name of employee19 Street address (including room or suite no.) 20City or town3Street address (including apartment no.) 21State or province 22Country and ZIP or foreign postal code 9Street address (including room or suite no.)10 Contact telephone number 23Part IVCovered Individuals (Enter the information for each covered individual(s).) 36Part IVCovered Individuals (Enter the information for each covered individual.)First name, middle initial, last name(b) SSN or other TINTIN is not available)Covered5State or province(e) Months of coverage 11 City or town 12State or province 13 Country and ZIP or foreign postal code 37 24(a) (a) Name of covered individual(s)(b) SSN (c)(c) DOB (if SSN or otherall 12 months (e) Months of coverageavailable) (d) Name of covered individual(s)DOB (If SSN is notCoveredJan JanMarApr Feb May 6 Country and ZIP or foreign postal code Nov June July Plan Start Month (enter 2-digit number): Dec 38 25 4City or town all 12 months NovDecDecPart II All 12 MonthsFeb JunJul Aug Sep May Oct Aug Sept Oct Nov2323 14Offer ofEmployee Offer of Coverage Jun Employees Age on January 1 This panelAug Sep OctMar Apr2424 Coverage (enter$ $ $ $ $ $ $ $ $ $ $ $ $ Contains 39 41-0852411 26 Form1095-B (2022)required code)15Employee 2525 Required1095 Copy B Backer RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 27Contribution (see 2025 image not available Information 40 28instructions) 16 Section 4980H Safe Harbor and Other Relief (enter code, if applicable)2626 at time of printing. Jan Feb Mar Apr May (e) Months of coverageAug Sept Oct Nov Dec FROM: 29 41-0852411 Form 1095-C (2022)17 ZIP CodeCovered Individuals30Part 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.2727(a) Name of covered individual(s) (b) SSN or other TIN DOB (if SSN or other (d) Covered2828 First name, middle initial, last name41-0852411 (c) TIN is not available)all 12 months 1095-B(2015) June July RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1095B Form1095-B(2022) Important Tax Document Enclosed 2025 image not availableFor Privacy Act and Paperwork Reduction Act Notice, see separate instructions.18 1095B Form First-Class Mail19 at time of printing.20 2025 image not available21 at time of printing. FROM:2223RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1095C Form1095-C(2022) Important Tax Document Enclosed 2025 image not availableFirst-Class MailThis panel 14035 at time of printing.Contains FROM:1095 Copy C Backer77771 or 77772 InformationImportant Tax Document Enclosed 2025 image not available2025 image not available First-Class Mailat time of printing. at time of printing.Eccentric ZFoldSheets per pack50500FORM DESCRIPTION1095-B HEALTH COVERAGE1095B501095B5001095-B Employee/Employer Copy Health Coverage N/AN1095B5001095-B Health Coverage Laser Cut Sheet - Alternate Format1094BT50N/A1094-B Transmittal Of Health Coverage Information Returns Transmittal For Form 1095-BN/APS1095B50014" Pressure Seal EZ-Fold 1095-B Employees Copy Health Coverage Bulk Pack1095-C EMPLOYER PROVIDED HEALTH INSURANCE OFFER & COVERAGE1095C501095C5001095-C Employee/Employer Copy Employer-Provided Health Insurance Offer And CoverageN/AN1095C5001095-C Employer-Provided Health Insurance Offer and Coverage Laser Cut Sheet - Alternate Format1095CIRS501095CIRS5001095-C IRS Copy Employer-Provided Health Insurance Offer And Coverage 1094CT50N/A1094-C Transmittal Of Employer-Provided Health Insurance Offer And Coverage Information Returns For Form 1095C,3-Page FormN/APS1095C50014 Pressure Seal EZ-Fold 1095-C Employees Copy Employer Health Insurance Offer And Coverage Bulk Pack1095-C CONTINUATION1095CIRSC50N/A Form 1095-C IRS Continuation Copy Employer-Provided Health Insurance Offer And Coverage1095-B OR C BLANK1095BCBLK501095BCBLK5001095-B And/Or 1095-C Blank W/Printed Backer InstructionsN/APS1095BC500BLK14" Pressure Seal EZ-Fold 1095-B and/or 1095-C Blank w/Printed Backer Instructions Bulk Pack SOFTWARE140352025 ACA Downloadable Software 34'