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 March2* 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 recipientsWhich months the insured and Self-insured employers, with fewerFeb. 28 paper; 1095-B Health Coverage his or her family was coveredthan 50 full-time employees, thatMarch 31 electronic* Yes, by March 2*under the plan provide health plans1094-B Transmittal of HealthSummary transmittal record Accompanies 1095-B formsFeb. 28 paper;#N/ACoverage Information Returns of 1095-Bs when mailed to IRS March 31 electronic*Employers with 50 or more1095-C Employer-ProvidedWhether or not the employerfull-time employees Feb. 28 paper; Health Insurance Offer andofferedhealth coverageto(Applicable Large Employers) March 31 electronic* Yes, by March 2*Coverage employees Both insured and self-insuredissue 1095-C1094-C Transmittal of Employer Provided Health Insurance OfferSummary transmittal record Summary transmittal record Feb. 28 paper;#N/Aand CoverageInformationof 1095-Cs of 1095-Cs March 31 electronic*Returns 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 2*Both insured and self-insuredissue 1095-C*Due to the uncertain status of the ACA, dates are subject to change. If any date shown falls on a Saturday, Sunday, or legal holiday, the due dateis the next business day.WHAT FORMS ARE AVAILABLE?IRS REPORTING RECIPIENT REPORTINGOnly the official IRS landscape format can be submitted when reportingEmployers provide the employee/recipient the approved Portrait format. to the Internal Revenue Service (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 file with the IRS landscape format only. The employer mustIRS LANDSCAPE FORMAT IS NOW TWO PAGESkeep a copy file and provide the recipient a copy for their records.Please note, Form 1095-C (IRS Landscape Format) is now two pages.1095-CIRS 600120Part III, for self-insured coverage that lists the employee and dependents Form1095-C Employer-Provided Health Insurance Offer and CoverageVOID OMB No. 1545-2251 who were enrolled in coverage moved to Page 3 (instructions are to2021Department of the Treasury Go to www.irs.gov/Form1095C for instructions and the latest information. CORRECTED 1095-CIRSC Internal Revenue ServiceDo not attach to your tax return. Keep for your records.8Page 2). This is an IRS requirement for employers to purchase an Part I Employee 2Social security number (SSN) Applicable Large Employer Member (Employer)1Name of employee (first name, middle initial, last name)7Name of employer 2022 image not available3Street 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 (e) Months of coverageAug Sept Oct 600320 3 additional form 1095CIRSC if dependents need to be reported. 4City or town 5State or province 11 City or town 12State or province Form 1095-C (2021) Page 13 Country and ZIP or foreign postal codePart 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, including the employee.Coverage (enterAll 12 Months Apr May June Aug Oct First name, middle initial, last nameDOB (if SSN or other (d) Covered June July Nov Dec 1094-CTNovat time of printing.14Offer of(a) Name of covered individual(s)required code)15Employee Required Contribution (see$ $ $ $ $ $ $ $ $ $ $ 18 $ $instructions) 16 Section 4980H 2022 image not availableSafe Harbor and Other Relief (enter19 120118code, if applicable)17 ZIP Code20 Form1095-C(2021) Form 1094-C Transmittal of Employer-Provided Health Insurance Offer and CORRECTED OMB No. 1545-2251RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1095CIRS Department of the Treasury Coverage Information Returns 2021 1095-BIRS21 Internal Revenue Service Go to www.irs.gov/Form1094C for instructions and the latest information.at time of printing.Part I Applicable Large Employer Member (ALE Member) 2 1 Name of ALE Member (Employer) 22 3 Street address (including room or suite no.) 5601182022 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 2021 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 Only2022 image not available12City or town 13 State or province 14 Country and ZIP or foreign postal code 8. 9Reserved 11011626 15Name of person to contact16 Contact telephone number 10 . Enter letter identifying Origin of the Health Coverage (see instructions for codes): 11 FormTransmittal of Health Coverage Information ReturnsOMB No. 1545-225227 17Reserved Part II Information About Certain Employer-Sponsored Coverage (see instructions) 1094-B Go to www.irs.gov/Form1094B for instructions and the latest information. 2021Employer name15Department of the Treasury 12 Street address (including room or suite no.) 13City or town 14State or province Internal Revenue Service 2Employer identi\x1fcation number (EIN)at 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 code2022 image not available30 41-0852411 1095CIRSC 20 Form1095-C(2021) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Part IV . . .(a). . . . . Yes No(b) SSN or other TINTIN is not available)Covered 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? . Covered Individuals (Enter the information for each covered individual.) (e) Months of coverageFirst name, middle initial, last name (c) DOB (if SSN or otherall 12 months 8 Country and ZIP or foreign postal codeName of covered individual(s)(d) 7 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(2021) SignatureTitle Date26 RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1094BT Form 1094-B(2021)2728RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1095BIRS Form1095-B(2021)51"