b'ACA FORMS ACA PRE-PRINTED FORMSOrdering ACA Forms Laser & Pressure Seal1095-B __ __ PS1095B500WHAT ARE THE AFFORDABLE CARE ACT (ACA) FORMS?__ 560118Form1095-B Health Coverage VOID OMB No. 1545-2252 PS1095B ____ Department of the TreasuryGo 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 IndividualForm Whats Reported? Who Issues? Submit to IRS? RecipientEmployer 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 PS1095C500Copies? Employer Address Line 3 8 Enter letter identifying Origin of the Health Coverage (see instructions for codes):14State or province 15Country and ZIP or foreign postal codeInformation About Certain Employer-Sponsored Coverage (see instructions)10Employer name12 Street address (including room or suite no.) 13City or townPart IIIIssuer or Other Coverage Provider (see instructions) Form1095-C Employer-Provided Health Insurance Offer and CoverageVOID 6001201095-BCBLK 16Name (a) Name of covered individual(s) (b) SSN or other TIN 20City or townCovered 1718Contact telephone numberDepartment of the Treasury Do not attach to your tax return. Keep for your records. CORRECTED OMB No. 1545-2251Which months the insured and Insurance carrier, for employersInsurance carrier submits: Yes, by March 2Policy Holder Name Part IVCovered Individuals (Enter the information for each covered individual.) Jan Feb Mar Apr May (e) Months of coverageAug Sep Part I Employee 2Social security number (SSN) Applicable Large Employer Member (Employer) PS1095C19 Street address (including room or suite no.) 21State or province 22Country and ZIP or foreign postal codeInternal Revenue Service Go to www.irs.gov/Form1095C for instructions and the latest information. 2022Name of employee (first name, middle initial, last name)7Name of employer 8 First name, middle initial, last name TIN is not available)all 12 months 31Street address (including apartment no.) 9Street address (including room or suite no.)10 Contact telephone number (c) DOB (if SSN or other (d) 1095-B Health Coverage his or her family was coveredwith employer-sponsored groupFeb. 28 paper; Insurance carrierPolicy Holder Address Line 1 23 Jun Jul Oct Nov Dec 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 24 4City or town Employee Offer of Coverage Feb Mar Employees Age on January 1 July Plan Start Month (enter 2-digit number): Dec PS1095BC500BLKPolicy Holder Address Line 3 Part II All 12 Months Jan Apr May June Aug Sept Oct Novunder the plan health plans March 31 electronic sends to recipients 25 14Offer of$ $ $ $ $ $ $ $ $ $ $ $ $FoldHere 2023 image not availableCoverage (enter required code)15Employee RequiredPS1095BCBLKContribution (see instructions) 26 16 Section 4980H Safe Harbor and Other Relief (enter FoldHere at time of printing.code, if applicable)2023 image not available27Which months the insured and Self-insured employers, with fewerForm1095-B Health Coverage VOID 560115 This panel 28 17 ZIP CodeCovered Individuals(b) SSN or other TIN DOB (if SSN or otherall 12 monthsJan Feb Mar Apr May (e) Months of coverageAug Sept Oct Nov Dec560118 Part III If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.OMB No. 1545-2252Feb. 28 paper;Form1095-BGo toHealth Coverage VOID OMB No. 1545-2252 Contains 29 18 First name, middle initial, last name (c) TIN is not available) (d) Covered JuneJulyDepartment of the Treasury Information about Form 1095-B and its separate instructions is at www.irs.gov/form1095b. CORRECTED 2020 (a) Name of covered individual(s) 1095-B Health Coverage his or her family was coveredthan 50 full-time employees, thatYes, by March 2 Internal Revenue Service Do not attach to your tax return. Keep for your records. CORRECTED 2022 30Department of the Treasury 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 ServiceMarch 31 electronic Part I Responsible Individual 5City or town 2 Social security number (SSN) or other TIN 3Country and ZIP or foreign postal code 1095 Copy B Backer 31 191Name of responsible individual, street address, city or town, state or province, country, and ZIP or foreign postal code1Name of responsible individualFirst name, middle name, last name 3 Date of birth (if SSN or other TIN is not available)9 7Date of birth (If SSN is not available)under the plan provide health plans 4 Street address (including apartment no.) 6State or province VOID 600120 Information 32 202023 image not available8 Enter letter identifying Origin of the Health Coverage (see instructions for codes):9Reserved8 Enter letter identifying Origin of the Policy (see instructions for codes): Part II Information About Certain Employer-Sponsored Coverage (see instructions) 11 . CORRECTED OMB No. 1545-2251 33 211010Employer name Form1095-C Employer-Provided Health Insurance Offer and Coverage Part II Employer Sponsored Coverage (If Line 8 is A or B, complete this part.) 11Employer name, street address, city or town, state or province, country, and ZIP or foreign postal code Do not attach to your tax return. Keep for your records12 Street address (including room or suite no.) Department of the TreasuryGo to www.irs.gov/Form1095C for instructions and the latest information. 2022 34 22Internal Revenue Service 13City or town 14State or province 15Country and ZIP or foreign postal codePart I Employee 2Social security number (SSN) Applicable Large Employer Member (Employer)at time of printing.Part IIIIssuer or Other Coverage Provider (see instructions) 17 7Name of employer 835 23Part IIIIssuer or Other Coverage Provider(first name, middle initial, last name) 18Contact telephone number 10 Contact telephone number1Name of employee1094-B Transmittal of HealthSummary transmittal record Accompanies 1095-B formsFeb. 28 paper;1616NameName, 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.)13 Country and ZIP or foreign postal code 36 2419 Street address (including room or suite no.) 22Country and ZIP or foreign postal code#N/A Part IVCovered Individuals (Enter the information for each covered individual(s).)6 Country and ZIP or foreign postal code11 City or town July Oct 12State or province Sept(enter 2-digit number): Dec 37 25(a) (a) Name of covered individual(s) 4City or town SSN 5State or province(d) Covered(e) Months of coveragePart IVCovered Individuals (Enter the information for each covered individual.)Coverage Information Returns of 1095-Bs when mailed to IRS March 31 electronic First name, middle initial, last name(b) SSN or other TIN DOB (if SSN or otherCovered FebMarEmployees Age on January 1 SepOct Plan Start Month Oct Nov 38 26 (c)(c) DOB (If SSN is notall 12 months (e) Months of coverageName of covered individual(s)Part II (b)Employee Offer of Coverage FebJanApr Jul Sep Nov DecDec14Offer ofAll 12 Months available) Jan all 12 monthsMar May JuneAugAug Aug(d) TIN is not available) MayJun NovCoverage (enter required code)2023 image not available2323 15Employee39 27Required Contribution (see$ $ $ $ $ $ $ $ $ $ $ $ $instructions) 2424 Safe Harbor and40 41-0852411 28 Form1095-B (2022)16 Section 4980H Employers with 50 or more 2525 code, if applicable) RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 29Other Relief (enter 1095-C Employer-ProvidedWhether or not the employerfull-time employees 2626 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 Dec FROM: 30 41-0852411 Form 1095-C (2022) g.Feb. 28 paper;2727 First name, middle initial, last name DOB (if SSN or other (d) Covered June July rintinPart 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) pHealth Insurance Offer andofferedhealth coverageto(Applicable Large Employers) Yes, by March 2 28For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1095B Form 1095-B(2015) This panelMarch 31 electronic 28 19 41-0852411 1095B Form 1095-B(2022) Important Tax Document Enclosed First-Class Mail e ofRAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.18timCoverage employees Both insured and self-insured Contains20 1095 Copy C Backer at issue 1095-C 21 Information FROM:1094-C Transmittal of Employer22 41-0852411 1095C Form1095-C(2022)23Provided Health Insurance OfferSummary transmittal record Summary transmittal record Feb. 28 paper;#N/A RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 14035 Important Tax Document Enclosed First-Class Mailand CoverageInformationof 1095-Cs of 1095-Cs March 31 electronic FROM:Returns Employers with 50 or more TFP 77771 or 77772 Important Tax Document Enclosed First-Class Mail1095-CIRSC Employer-Providedfull-time employeesHealth Insurance Offer andAdditional covered individuals(Applicable Large Employers) Feb. 28 paper;Yes, by March 2Coverage (Continuation Form)Both insured and self-insured March 31 electronicissue 1095-CIf any date shown falls on a Saturday, Sunday, or legal holiday, the due dateis the next business day.Eccentric WHAT FORMS ARE AVAILABLE? APEX - Sheets per packTFP - Forms per pack FORM DESCRIPTION ZFold50s500s100s500s IRS REPORTING RECIPIENT REPORTING 1095-B HEALTH COVERAGE1095B501095B5001095B1095B5001095-B Employee/Employer Copy Health Coverage Only the official IRS landscape format can be submitted when reportingEmployers provide the employee/recipient the approved Portrait format.N1095B50N1095B500N1095BN1095B5001095-B Health Coverage Laser Cut Sheet - Alternate Formatto the Internal Revenue Service (IRS). These are available in pre-printed or blank form version designed to1095BIRS501095BIRS5001095BIRS1095BIRS5001095-B IRS Copy Health Coverageaccommodate envelope 77771 or DWMR. We recommend you review1094BT501094BT5001094BT1094BT5001094-B Transmittal Of Health Coverage Information Returns Transmittal For Form 1095-BEMPLOYER FILE COPY AND REPORTING software compatibility. #N/APS1095B500#N/APS1095B50014" Pressure Seal EZ-Fold 1095-B Employees Copy Health Coverage Bulk Pack Employers file with the IRS landscape format only. The employer mustIRS LANDSCAPE FORMAT IS NOW TWO PAGES #N/A#N/APSN1095B#N/APressure Seal 1095-B Health CoveragePressure Seal - Alternate Formatkeep a copy file and provide the recipient a copy for their records. 1095-B CONTINUATIONPlease note, Form 1095-C (IRS Landscape Format) is now two pages. 1095BC50#N/A1095BC#N/A1095-B Continuation Employee/Employer Copy Health Coverage1095-CIRS 600120Part III, for self-insured coverage that lists the employee and dependents1095BIRSC50#N/A1095BIRSC#N/A1095-B IRS Continuation Copy Health Coverage Form1095-C Employer-Provided Health Insurance Offer and CoverageVOID OMB No. 1545-2251 who were enrolled in coverage moved to Page 3 (instructions are to 1095-C EMPLOYER PROVIDED HEALTH INSURANCE OFFER & COVERAGEDepartment of the TreasuryGo to www.irs.gov/Form1095C for instructions and the latest information CORRECTED 2022Internal Revenue Service Do not attach to your tax return. Keep for your records81095-CIRSC Part I Employee 2Social security number (SSN) Applicable Large Employer Member (Employer) Page 2). This is an IRS requirement for employers to purchase an1095C501095C500#N/A1095C5001095-C Employee/Employer Copy Employer-Provided Health Insurance Offer And Coverage1Name of employee (first name, middle initial, last name)7Name of employer 2023 image not availableav ble3Street address (including apartment no.)Jan Feb6 Country and ZIP or foreign postal code9Street address (including room or suite no.)Sept 10 Contact telephone number Dec (b) SSN or other TIN (c) TIN is not available)all 12 monthsJan Feb Mar Apr May June ncluding the employee. Oct 600320 3 additional form 1095CIRSC if dependents need to be reported.N1095C50N1095C500N1095CN1095C5001095-C Employer-Provided Health Insurance Offer and Coverage Laser Cut Sheet - Alternate Format4City or town 5State or province 11 City or town 12State or province 13 Country and ZIP or foreign postal code Page Form 1095-C (2021)Part IIICovered Individuals Part II Employee Offer of Coverage Mar Employees Age on January 1 July Plan Start Month (enter 2-digit number):If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, i14Offer ofAll 12 Months Apr May June Aug Oct (a) Name of covered individual(s) DOB (if SSN or other (d) Covered (e) Months of coverageAug Sept Nov Dec 1094-CTNovat time of printing. ot ailaCoverage (enter$ $ $ $ $ $ $ $ $ $ $ 18 First name, middle initial, last name $ $ July 1095CIRS50#N/A#N/A1095CIRS5001095-C IRS Copy Employer-Provided Health Insurance Offer And Coverage required code)15Employee Required Contribution (see instructions) 16 Section 4980H19 Transmittal of Employer-Provided Health Insurance Offer and CORRECTED 120118 1094CT501094CT5001094CT1094CT5001094-C Transmittal Of Employer-Provided Health Insurance Offer And CoverageSafe Harbor and Other Relief (enter code, if applicable)17 ZIP Code41-0852411 20 Form1095-C(2022) Form 1094-C Coverage Information Returns OMB No. 1545-2251RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 1095CIRS Department of the Treasury Go to www.irs.gov/Form1094C for instructions and the latest information. 2022 1095-BIRS Information Returns For Form 1095C-3 Page Form21 Internal Revenue Service202 at time of printing.Part I Applicable Large Employer Member (ALE Member) 2 1 Name of ALE Member (Employer) 22 age n 3 Street address (including room or suite no.) 5 State or province 6 Country and ZIP or foreign postal code Form1095-B Health Coverage VOID 560118 #N/APS1095C500#N/APS1095C50014" Pressure Seal EZ-Fold 1095-C Employees Copy Employer Health Insurance Offer And CoverageBulk Pack 3 im 2023 image not available23 4 City or town 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 information25 9 Name of Designated Government Entity (only if applicable)10Part I Responsible Individual 5City or town 2 Social security number (SSN) or other TIN 3 Date of birth (if SSN or other TIN is not available) 1095-C CONTINUATION1Name of responsible individualFirst name, middle name, last nameat time of printing.11Street address (including room or suite no.) For Ofcial Use Only 6State or province 7Country and ZIP or foreign postal code4 Street address (including apartment no.)26 12City or town 13 State or province 14 Country and ZIP or foreign postal code 8 Enter letter identifying Origin of the Health Coverage (see instructions for codes): . 9Reserved 11 Form1094-B Transmittal of Health Coverage Information Returns110116 1095CC50#N/A1095CC#N/AForm 1095-C Continuation Employee/Employer Copy Employer-Provided Health Insurance Offer And Coverage2023 image not available15Name of person to contact16 Contact telephone number OMB No. 1545-2252Part II Information About Certain Employer-Sponsored Coverage (see instructions)27 17Reserved 10 . Employer name 13City or town 14State or province 15Department of the TreasuryGo to www.irs.gov/Form1094B for instructions and the latest information. 2 202228 18Total number of Forms 1095-C submitted with this transmittal 12 Street address (including room or suite no.) . . . . . . . (see instructions) 17Internal Revenue Service Employer identi\x1fcation number (EIN) 1095CIRSC50#N/A1095CIRSC#N/AForm 1095-C IRS Continuation Copy Employer-Provided Health Insurance Offer And Coverageat time of printing.Country and ZIP or foreign postal code1 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 Provider18Contact telephone number 4 Contact telephone number29 Part II ALE Member Information . 19 Street address (including room or suite no.) .20City or town 21State or province 3 Name of person to contact 6 City or town #N/A#N/APSN1095C#NAPressure Seal 1095-C Employer-Provided Health Insurance Offer and Coverage - Alternate Format16Name2023 image not available22Country and ZIP or foreign postal code30 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.) 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 TINDOB (if SSN or otherCovered(e) Months of coverage 8 Country and ZIP or foreign postal codeYes all 12 months 7 State or province Oct Nov DecName of covered individual(s)(c) TIN is not available) (d) 22Certications of Eligibility (select all that apply):Jan Feb Mar Apr May Jun Jul Aug Sep 1095-B OR C BLANKIf No, do not complete Part IV.at time of printing.A. Qualifying Offer Method B. Reserved C. Reserved D. 98% Offer Method 9Total number of Forms 1095-B submitted with this transmittal 1095BCBLK501095BCBLK500#N/A1095BCBLK5001095-B And/Or 1095-C Blank W/Printed Backer Instructions23Under 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.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.24SignatureTitle 41-0852411 Date 25 Form1094-C(2022) SignatureTitle 41-0852411 1094BT Date Form 1094-B(2022) #N/APS1095BC500BLK#N/APS1095BC500BLK14" Pressure Seal EZ-Fold 1095-B and/or 1095-C Blank w/Printed Backer Instructions Bulk Pack RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 1094CT26 RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.27 SOFTWARE & CD28 41-0852411 1095BIRS Form1095-B(2022) 14035 RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 2023 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. 14 15'