b'PRE-PRINTED ACA FORMSLASER & PRESSURE SEAL1095B PS1095B500 __ __ __ 1A560115Form1095-B Health Coverage VOID OMB No. 1545-2252 ____ Department of the TreasuryInformation about Form 1095-B and its separate instructions is at www.irs.gov/form1095b. CORRECTED 2020 PS1095BInternal Revenue ServiceEmployer Name A Part I Responsible Individual 2 Social security number (SSN) 3 Date of birth (If SSN is not available)1Name of responsible individualEmployer Address Line 1 4 Street address (including apartment no.) 5City or town 6State or province 7Country and ZIP or foreign postal codeEmployer Address Line 2 9Employer Address Line 3 1095C 8 Enter letter identifying Origin of the Policy (see instructions for codes): Part IIEmployer Sponsored Coverage (see instructions) 11 PS1095C50010Employer name1A12 Street address (including room or suite no.) 13City or town 14State or province 15Country and ZIP or foreign postal code Part IIIIssuer or Other Coverage Provider (see instructions) VOID 600116 19 Street address (including room or suite no.) 21State or province 1095-C Information about Form 1095-C and its separate instructions is at www.irs.gov/form1095c. 20201095BCBLK 16Name 20City or town 1718Contact telephone numberFormEmployeeEmployer-Provided Health Insurance Offer and Coverage CORRECTED OMB No. 1545-2251PS1095C22Country and ZIP or foreign postal codeDepartment of the Treasury Internal Revenue Service2Social security number (SSN) Applicable Large Employer Member (Employer)Part IPart IVCovered Individuals (Enter the information for each covered individual(s).) A 1Name of employee7Name of employer 8 Policy Holder Name (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is notCovered JanFebMarAprMay (e) Months of coverage Aug Sep 3Street address (including apartment no.) 9Street address (including room or suite no.)10 Contact telephone number(d) Policy Holder Address Line 1 available) all 12 monthsJunJul 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 23 4City or town Employee Offer and Coverage Plan Start Month (Enter 2-digit number):Policy Holder Address Line 3 24 Part II All 12 Months Jan Feb Mar Apr May June July Aug Sept 1A Oct Nov Dec PS1095BC500BLK14Offer of Coverage (enter required code)25 15Employee Share of Lowest Cost for Self-Only$ $ $ $ $ $ $ $ $ $ $ $ $ PS1095BCBLKMonthly Premium, Minimum Value 26 Coverage16Applicable Section 4980H Safe Harbor (enter code, VOID 560115 27 if applicable) Covered Individuals(b) SSN DOB (If SSN is (d) Covered Jan Feb Mar Apr MayJuneJuly A Sept Oct Nov DecPart III If Employer provided self-insured coverage, check the box and enter the information for each covered individual.Form1095-B Health Coverage CORRECTED OMB No. 1545-2252 This panel 28 17 (a) Name of covered individual(s) (c)not available) all 12 months (e) Months of CoverageAugDepartment of the TreasuryInformation about Form 1095-B and its separate instructions is at www.irs.gov/form1095b. 2020 29Internal Revenue Service 2 Social security number (SSN) Contains O G 30 18 O GPart I Responsible Individual (Policy Holder)1Name of responsible individual, street address, city or town, state or province, country, and ZIP or foreign postal code 3 Date of birth (If SSN is not available) 1095 Copy B Backer 31 199 Information 32 208 Enter letter identifying Origin of the Policy (see instructions for codes): Part II Employer Sponsored Coverage (If Line 8 is A or B, complete this part.) 11 600120 33 21FoldHere Pat. Nos. 4,918,128; 4,928,875 and other pats. - 22110Employer name, street address, city or town, state or province, country, and ZIP or foreign postal codeVOIDForm1095-C Employer-Provided Health Insurance Offer and CoverageCORRECTED OMB No. 1545-2251 34 22 Part III Department of the Treasury Go to www.irs.gov/Form1095C for instructions and the latest information 2020 35 23Internal Revenue ServiceDo not attach to your tax return. Keep for your recordsIssuer or Other Coverage Provider Employee17 2Social security number (SSN) Applicable Large Employer Member (Employer) 36 O G 24 O GPart I 18Contact telephone number16Name, street address, city or town, state or province, country, and ZIP or foreign postal code7Name of employer 8 1Name of employee (first name, middle initial, last name)3Street address (including apartment no.) 9Street address (including room or suite no.)10 Contact telephone numberPart IVCovered Individuals (Enter the information for each covered individual(s).) Feb (e) Months of coverage 12State or province 13 Country and ZIP or foreign postal code 37 25available) (d) (b) SSN (c) DOB (If SSN is notall 12 months6 Country and ZIP or foreign postal codeJulAug(a) Name of covered individual(s) 4City or town 5State or province Covered JanMarAprMayJun 11 City or townSepOctNovDec 38 26Part II Employee Offer of Coverage Feb Mar Employees Age on January 1 July Plan Start Month (enter 2-digit number): Dec 39 27PressureSeal 23 14Offer ofAll 12 Months Jan Apr May June Aug Sept Oct NovPat. Nos. 4,918,128; 4,928,875 and other pats. - 221 PressureSeal Coverage (enter required code) 40 41-0852411 28Form 1095-B (2016)24 15EmployeeXID #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.Required Contribution (see$ $ $ $ $ $ $ $ $ $ $ $ $ 29instructions) 25 16 Section 4980H Safe Harbor and Other Relief (enterFROM: 30code, if applicable)INSTRUCTIONS OPENINGFORSIDEREVERSESEEINSTRUCTIONS26 3117 ZIP CodeCovered Individuals3227 Part III If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.(a) Name of covered individual(s) DOB (if SSN or other (d) Covered (e) Months of coverage 28 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 33 41-0852411 1095B Form 1095-B(2015) This panel Important Tax Document Enclosed First-Class MailOPENINGPressureSeal Pat. Nos. 4,918,128; 4,928,875 and other pats. - 221For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.18 34 Contains XID #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 Form 1095-C (2015)19 1095 Copy C Backer FROM:20 Information212223 Important Tax Document Enclosed First-Class MailRAA #1607For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 1095C Form1095-C(2020)FORSIDEREVERSESEE 14035 FROM:SEE REVERSE SIDE FOR OPENING INSTRUCTIONSTFP 7777-2Important Tax Document Enclosed First-Class MailEccentric ZFoldMFG SKU Sheets per packMFG ID Forms per pack50s500s100s500sFORM DESCRIPTION1095B HEALTH COVERAGE1095B501095B5001095B1095B500Laser 1095B Employee/Employer Copy Health Coverage 1095BIRS501095BIRS5001095BIRS1095BIRS500Laser 1095B IRS Copy Health Coverage1094BT501094BT5001094BT1094BT500Laser 1094B Transmittal Of Health Coverage Information Returns Transmittal For Form 1095B#N/APS1095B500#N/APS1095B50014" Pressure Seal EZ-Fold 1095B Employees Copy Health Coverage Bulk Pack 1095B CONTINUATION1095BC50#N/A1095BC#N/ALaser 1095B Continuation Employee/Employer Copy Health Coverage1095BIRSC50#N/A1095BIRSC#N/ALaser 1095B IRS Continuation Copy Health Coverage 1095C EMPLOYER PROVIDED HEALTH INSURANCE OFFER & COVERAGE1095C501095C5001095C1095C500Laser 1095C Employee/Employer Copy Employer-Provided Health Insurance Offer And Coverage1095CIRS501095CIRS5001095CIRS1095CIRS500Laser 1095C IRS Copy Employer-Provided Health Insurance Offer And Coverage 1094CT501094CT5001094CT1094CT500Laser 1094C Transmittal Of Employer-Provided Health Insurance Offer And CoverageInformation Returns For Form 1095C-3 Page Form#N/APS1095C500#N/APS1095C50014" Pressure Seal EZ-Fold 1095C Employees Copy Employer Health Insurance Offer And Coverage Bulk Pack 1095C CONTINUATION1095CC50#N/A1095CC#N/AForm 1095C Continuation Employee/Employer Copy Employer-Provided Health Insurance Offer And Coverage1095CIRSC50#N/A1095CIRSC#N/AForm 1095C IRS Continuation Copy Employer-Provided Health Insurance Offer And Coverage1095B OR C BLANK1095BCBLK501095BCBLK5001095BCBLK1095BCBLK500Laser 1095B And/Or 1095C Blank W/Printed Backer Instructions#N/APS1095BC500BLK#N/APS1095BC500BLK14" Pressure Seal EZ-Fold 1095B and/or 1095C Blank w/Printed Backer Instructions Bulk Pack SOFTWARE & CD140352019 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. 53'