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 andInsurance carrier, for employersInsurance carrier submits: Yes, by January 31* 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 andSelf-insured employers, withFeb. 28 paper; 1095-B Health Coverage his or her family was coveredfewer than 50 full-time employees,March 31 electronic* Yes, by January 31*under the plan that provide health plans1094-B Transmittal of HealthSummary transmittalrecord ofAccompanies 1095-B formswhenFeb. 28 paper;#N/ACoverage Information Returns 1095-Bs mailed to IRS March 31 electronic*1095-C Employer-ProvidedWhether or not the employerEmployers with50 or more full-Health Insurance Offer andofferedhealth coveragetotimeemployees(Applicable LargeFeb. 28 paper;Yes, by January 31*Coverage employees Employers) Both insured and self- March 31 electronic*insured issue 1095-C1094-C Transmittal of Employer Provided HealthSummary transmittalrecord ofSummary transmittalrecord ofFeb. 28 paper;#N/AInsurance Offer and Coverage 1095-Cs 1095-Cs March 31 electronic*Information Returns 1095CIRSC Employer-ProvidedEmployers with50 or more full-Health Insurance Offer and(explanation pending) timeemployees(Applicable LargeFeb. 28 paper;Yes, by January 31*Coverage (Continuation Form)Employers) Both insured and self- March 31 electronic*insured issue 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 AVAILABLEIRS REPORTING RECIPIENT REPORTINGOnly the official IRS landscape format can be submitted whenEmployers provide the employee/recipient the approved Portrait reporting to the Internal Revenue Service (IRS). format. These are available in pre-printed or blank form version designed to accommodate envelope 77771 or DWMR. We EMPLOYER FILE COPY AND REPORTING recommend you review 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. Part III, for self-insured coverage that lists the employee 1095CIRS and dependents who were enrolled in coverage moved to Page Form 1094-C Transmittal of Employer-Provided Health Insurance Offer and CORRECTED 120118 3 (instructions are to Page 2). This is a major change requiring OMB No. 1545-2251Department of the Treasury Coverage Information Returns 2020Internal Revenue Service Go to www.irs.gov/Form1094C for instructions and the latest information. 1095CIRSCemployers to purchase an additional form (1095CIRSC50) to Part I Applicable Large Employer Member (ALE Member) 2 1 Name of ALE Member (Employer) 3 Street address (including room or suite no.) 5 State or province 6 Country and ZIP or foreign postal code Form 1095-C (2020) 600320 3 maintain compliance with the IRS.4 City or town Page 7 Name of person to contact 8 Contact telephone number Part IIICovered Individuals If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.9 Name of Designated Government Entity (only if applicable)1018 First name, middle initial, last name (b) SSN or other TIN (c) TIN is not available)all 12 monthsJan Feb Mar Apr May (e) Months of coverage Aug Sept Oct Nov Dec 1094CT(a) Name of covered individual(s) DOB (if SSN or other (d) Covered June July 11Street address (including room or suite no.) For Ofcial Use Only12City or town 13 State or province 14 Country and ZIP or foreign postal code15Name of person to contact16 Contact telephone number 19 VOID 60012020 Form1095-C Employer-Provided Health Insurance Offer and CoverageCORRECTED OMB No. 1545-225117Reserved . Department of the Treasury Go to www.irs.gov/Form1095C for instructions and the latest information 2020Internal Revenue ServiceDo not attach to your tax return. Keep for your records18Total number of Forms 1095-C submitted with this transmittal . . . . . . . . . . . 21 . . . . . . . . FoldHere Part I Employee 2Social security number (SSN) Applicable Large Employer Member (Employer) 1095BIRS1Name of employee (first name, middle initial, last name)7Name of employer 8 19Is this the authoritative transmittal for this ALE Member? If Yes, check the box and continue. If No, see instructions3Street address (including apartment no.) 9Street address (including room or suite no.)10 Contact telephone numberPart II ALE Member Information 22 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 code 56011820 Part IIEmployee Offer of Coverage Feb Mar Employees Age on January 1 July Plan Start Month (enter 2-digit number): DecDo not attach to your tax return. Keep for your records. VOID OMB No. 1545-225221Is ALE Member a member of an Aggregated ALE Group?23. Yes No Coverage (enterAll 12 Months Jan Apr May June Aug Sept Oct Form1095-B Health Coverage CORRECTED 2020FoldHereIf No, do not complete Part IV. 24 14Offer ofDepartment of the Treasury Go to www.irs.gov/Form1095B for instructions and the latest information. 3 Date of birth (if SSN or other TIN is not available) 1094BTNovInternal Revenue Service22Certications of Eligibility (select all that apply): required code) Part I Responsible Individual 2 Social security number (SSN) or other TIN15Employee1Name of responsible individualFirst name, middle name, last nameRequired Contribution (see A. Qualifying Offer Method B. Reserved C. Reserved D. 98% Offer Method instructions)$ $ $ $ $ $ $ $ $ $ $ 4 Street address (including apartment no.) $ $ 5City or town 6State or province 7Country and ZIP or foreign postal code25 16 Section 4980H Safe Harbor and110116Under 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. 26 Other Relief (enter8 Enter letter identifying Origin of the Health Coverage (see instructions for codes): . 9Reserved 11 OMB No. 1545-2252code, if applicable)SignatureTitle Date 17 ZIP CodeCovered IndividualsPart II Information About Certain Employer-Sponsored Coverage (see instructions) Form1094-B Transmittal of Health Coverage Information Returns202010Employer nameRAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1094CT27 Form1094-C(2020) Part III 12 Street address (including room or suite no.) 13City or town 14State or province 15Country and ZIP or foreign postal code Go to www.irs.gov/Form1094B for instructions and the latest information.Department of the Treasury If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee. Oct Issuer or Other Coverage Provider (see instructions) 17Internal Revenue Service 2Employer identi\x1fcation number (EIN)(a) Name of covered individual(s) (b) SSN or other TIN DOB (if SSN or other (d) Covered (e) Months of coverage Part III 1 Filer's name28 First name, middle initial, last name(c) TIN is not available)all 12 monthsJan Feb Mar Apr May June July Aug Sept Nov Dec 18Contact telephone number16Name18 19 Street address (including room or suite no.) 20City or town 21State or province 22Country and ZIP or foreign postal code 4 Contact telephone number3 Name of person to contact29 Part IVCovered Individuals (Enter the information for each covered individual.) (e) Months of coverage 5 Street address (including room or suite no.) 6 City or town(a) Name of covered individual(s)(b) SSN or other TIN (c) DOB (if SSN or otherall 12 months (d) Covered 30 41-0852411 1095CIRSC 19 Form1095-C(2020) First name, middle initial, last name TIN is not available)JanFebMarAprMayJun JulAug Sep Oct Nov Dec 8 Country and ZIP or foreign postal code For Ofcial Use OnlyRAA #1607 7 State or province202321 9Total number of Forms 1095-B submitted with this transmittal 2422 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.2523RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1095C 26 Form1095-C(2020) SignatureTitle Date27 RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1094BT Form 1094-B(2020)28RAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1095B Form 1095-B(2020)52"