b'PRE-PRINTED ACA FORMSLaser & Pressure Seal1095-B __ __ PS1095B500 __560118Form1095-B Health Coverage . VOID OMB No. 1545-2252Department of the Treasury Do not attach to your tax return. Keep for your records CORRECTED 2021 PS1095B ____Internal Revenue Service Go to www.irs.gov/Form1095B for instructions and the latest information.Part I Responsible Individual 2 Social security number (SSN) or other TIN 3 Date of birth (if SSN or other TIN is not available)Employer Name 1Name of responsible individualFirst name, middle name, last name 5City or town 6State or province 7Country and ZIP or foreign postal codeEmployer Address Line 1 4 Street address (including apartment no.)Employer 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) 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. 1545-225119 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. 2021 PS1095CPart I Employee 2Social security number (SSN) Applicable Large Employer Member (Employer)Part IVCovered Individuals (Enter the information for each covered individual.) (e) Months of coverageName of employee (first name, middle initial, last name)7Name of employer 8(c) DOB (if SSN or other (d)31Street address (including apartment no.) Policy Holder Name First name, middle initial, last name TIN is not available)all 12 months Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec9Street address (including room or suite no.)10 Contact telephone numberPolicy 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 2022 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)2022 image not available27 ZIP CodeCovered Individuals 560115 Part IIIForm1095-BHealth Coverage VOID OMB No. 1545-2252 This panel 28 17If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee. Oct Nov Dec560118Form1095-B Health Coverage VOID OMB No. 1545-2252 29 (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 coverageAug SeptDepartment of the Treasury Information about Form 1095-B and its separate instructions is at www.irs.gov/form1095b. CORRECTED 2020 First name, middle initial, last name DOB (if SSN or otherall 12 months JuneJulyInternal Revenue ServiceGo to www.irs.gov/Form1095B for instructions and the latest information CORRECTED 2021 Contains 30 18Department of the Treasury Do not attach to your tax return. Keep for your recordsPart I Responsible Individual (Policy Holder)at time of printing.Internal Revenue Service 2 Social security number (SSN)Part I Responsible Individual 2 Social security number (SSN) or other TIN 3Date of birth (if SSN or other TIN is not available) 1095 Copy B Backer 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 is not available)4 Street address (including apartment no.) 5City or town . 6State or province 7Country and ZIP or foreign postal code VOID 600120 Information 31 2092022 image not available8 Enter letter identifying Origin of the Health Coverage (see instructions for codes): . 9Reserved 328 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.)Employer name, street address, city or town, state or province, country, and ZIP or foreign postal codeDo not attach to your tax return. Keep for your records 2212 Street address (including room or suite no.) Department of the TreasuryGo to www.irs.gov/Form1095C for instructions and the latest information 2021Internal 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) 34at 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 employee1616NameName, street address, city or town, state or province, country, and ZIP or foreign postal code3Street address (including apartment no.) 9Street address (including room or suite no.) 19 Street address (including room or suite no.) 20City or town 21State or province 22Country and ZIP or foreign postal code 36 24Part 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 codeFirst name, middle initial, last name 4City or town SSN 5State or province(d) Covered Employees Age on January 1 Plan Start Month (enter 2-digit number): Dec 37 25Part IVCovered Individuals (Enter the information for each covered individual.)(a) (a) Name of covered individual(s)(b) SSN or other TINTIN is not available)Covered(e) Months of coverage (c)(c) DOB (if SSN or otherall 12 months (e) Months of coverageName of covered individual(s)Part II (b)Employee Offer of Coverage Feb Apr AugSepJulyOctOctNovAugNov DecDecSept Oct Nov 2614Offer of DOB (If SSN is not JanFebMarMar MayJulJuneAug Sep 38(d) All 12 Months available) Jan all 12 months MayJunCoverage (enter required code)2022 image not available2323 Required39 2715Employee Contribution (see$ $ $ $ $ $ $ $ $ $ $ $ $instructions) 2424 16 Section 4980H40 41-0852411 28 Form1095-B (2021)Safe Harbor and Other Relief (enter code, if applicable) RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 292525at time of printing.2626 17 ZIP CodeCovered IndividualsFROM: 30 41-0852411 Form 1095-C (2021)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(2021)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(2021)Important Tax Document Enclosed First-Class Mail14035 FROM:TFP 77771 or 77772Important Tax Document Enclosed First-Class MailEccentric ZFoldAPEX - Sheets per packTFP - Forms per pack50s500s100s500sFORM DESCRIPTION1095-B HEALTH COVERAGE1095B501095B5001095B1095B5001095-B Employee/Employer Copy Health Coverage 1095BIRS501095BIRS5001095BIRS1095BIRS5001095-B IRS Copy Health Coverage1094BT501094BT5001094BT1094BT5001094-B Transmittal Of Health Coverage Information Returns Transmittal For Form 1095-B#N/APS1095B500#N/APS1095B50014" Pressure Seal EZ-Fold 1095-B Employees Copy Health Coverage Bulk Pack 1095-B CONTINUATION1095BC50#N/A1095BC#N/A1095-B Continuation Employee/Employer Copy Health Coverage1095BIRSC50#N/A1095BIRSC#N/A1095-B IRS Continuation Copy Health Coverage 1095-C EMPLOYER PROVIDED HEALTH INSURANCE OFFER & COVERAGE1095C501095C5001095C1095C5001095-C Employee/Employer Copy Employer-Provided Health Insurance Offer And Coverage1095CIRS501095CIRS5001095CIRS1095CIRS5001095-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 Form#N/APS1095C500#N/APS1095C50014" Pressure Seal EZ-Fold 1095-C Employees Copy Employer Health Insurance Offer And Coverage Bulk Pack 1095-C CONTINUATION1095CC50#N/A1095CC#N/AForm 1095-C Continuation Employee/Employer Copy Employer-Provided Health Insurance Offer And Coverage1095CIRSC50#N/A1095CIRSC#N/AForm 1095-C IRS Continuation Copy Employer-Provided Health Insurance Offer And Coverage1095-B OR C BLANK1095BCBLK501095BCBLK5001095BCBLK1095BCBLK5001095-B And/Or 1095-C Blank W/Printed Backer Instructions#N/APS1095BC500BLK#N/APS1095BC500BLK14" Pressure Seal EZ-Fold 1095-B and/or 1095-C Blank w/Printed Backer Instructions Bulk Pack SOFTWARE & CD140352022 ACA Software: Includes ACA Forms & Transmittals; Can Create, Print And E-File Forms Through the Software. Allows You To Output Data On The Pre-Printed Vertical Format Forms. 52'