Page 4 - Pressure Seal Tax Catalog
P. 4

Stock Pressure Seal 1095C & 1095B                                                                                          Stock Pressure Seal Multi-Purpose
                                 AFFORDABLE CARE ACT FORMS
                     ACA                                                                                                                                      SLIDE FINGER BETWEEN FRONT & MIDDLE PANEL TO OPEN
                                                                                                                                                                REMOVE SIDE EDGES FIRST
                     AFFORDABLE                                             SLIDE FINGER BETWEEN FRONT & MIDDLE PANEL TO OPEN
                                                                               REMOVE SIDE EDGES FIRST
                                                                               REMOVE SIDE EDGES FIRST
                                                                            SLIDE FINGER BETWEEN FRONT & MIDDLE PANEL TO OPEN
                      CARE ACT
                        REMOVE SIDE EDGES FIRST
                                                                     Instructions for Recipient
                                                                                        3
                     SLIDE FINGER BETWEEN FRONT & MIDDLE PANEL TO OPEN  Employer  Form 1095-C (2024)  1F. Minimum essential coverage NOT providing minimum value offered to you, or you and your spouse or dependent(s), or Page 2
                                             Employee’s Age 1095–C
                                                                                  you, your spouse, and dependent(s).
                                                                     You are receiving this Form 1095-C because your employer is an Applicable Large Employer subject to the employer shared
                                      Page 2                         responsibility provisions in the Affordable Care Act. This Form 1095-C includes information about the health insurance cover-  1G. You were NOT a full-time employee for any month of the calendar year but were enrolled in self-insured employer-spon-
              Form 1095-C (2024)             2   Form   Provided     age offered to you by your employer. Form 1095-C, Part II, includes information about the coverage, if any, your employer  sored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box or in the
                                                                                  separate monthly boxes for all 12 calendar months on line 14.
              Instructions for Recipient  1F. Minimum essential coverage NOT providing minimum value offered to you, or you and your spouse or dependent(s), or  OMB No. 1545–2251  offered to you and your spouse and dependent(s). If you purchased health insurance coverage through the Health Insurance
              You are receiving this Form 1095-C because your employer is an Applicable Large Employer subject to the employer shared  you, your spouse, and dependent(s).  CORRECTED  600120  on January 1   Health  Marketplace and wish to claim the premium tax credit, this information will assist you in determining whether you are eligible.  1H. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum
                                                                                  essential coverage).
                                                                     If you or your family members are eligible for certain types of minimum essential coverage, you may not be eligible for the
                           1G. You were NOT a full-time employee for any month of the calendar year but were enrolled in self-insured employer-spon-
              responsibility provisions in the Affordable Care Act. This Form 1095-C includes information about the health insurance cover-  sored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box or in the Part II  Employee Offer  16 Section  17 Zip Code   premium tax credit. For more information about the premium tax credit, see Pub. 974, Premium Tax Credit (PTC).  1I. Reserved for future use.
                                 VOID
              age offered to you by your employer. Form 1095-C, Part II, includes information about the coverage, if any, your employer  of Coverage   Insurance  You may receive multiple Forms 1095-C if you had multiple employers during the year that were Applicable Large  1J. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered to
              offered to you and your spouse and dependent(s). If you purchased health insurance coverage through the Health Insurance  separate monthly boxes for all 12 calendar months on line 14.  14 Offer of 15 Employee Required  4980H Safe  your spouse; and minimum essential coverage NOT offered to your dependent(s).
              Marketplace and wish to claim the premium tax credit, this information will assist you in determining whether you are eligible.  1H. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum Plan Start  Coverage  Contribution   Harbor and  Employers (for example, you left employment with one Applicable Large Employer and began a new position of employment
                            state or province, country, ZIP or foreign postal code, and telephone no.
                           1J. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered to Mo. (Enter
              If you or your family members are eligible for certain types of minimum essential coverage, you may not be eligible for the  essential coverage). APPLICABLE LARGE EMPLOYER’S name, street address, city or town,  (enter  (see instructions)  Other Relief  Offer and  with another Applicable Large Employer). In that situation, each Form 1095-C would have information only about the health  1K. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered     41884               PSDBPCD
                                                                                  to your spouse; and minimum essential coverage offered to your dependent(s).
                                             (enter code,
                           1I. Reserved for future use.
                                                                     insurance coverage offered to you by the employer identified on the form. If your employer is not an Applicable Large
              premium tax credit. For more information about the premium tax credit, see Pub. 974, Premium Tax Credit (PTC).  Part I  required  Employer, it is not required to furnish you a Form 1095-C providing information about the health coverage it offered. In addi-  1L. Individual coverage health reimbursement arrangement (HRA) offered to you only with affordability determined by using
              You may receive multiple Forms 1095-C if you had multiple employers during the year that were Applicable Large  2-digit no.):  code)  if applicable)  Coverage  employee’s primary residence ZIP code.  FOLD, CREASE AND TEAR ALONG PERFORATION  REMOVE THESE EDGES FIRST
              Employers (for example, you left employment with one Applicable Large Employer and began a new position of employment G  your spouse; and minimum essential coverage NOT offered to your dependent(s).  tion, if you, or any other individual who is offered health coverage because of their relationship to you (referred to here as  1M. Individual coverage HRA offered to you and dependent(s) (not spouse) with affordability determined by using employee’s
              with another Applicable Large Employer). In that situation, each Form 1095-C would have information only about the health  1K. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered  family members), enrolled in your employer’s health plan and that plan is a type of plan referred to as a “self-insured” plan,
              insurance coverage offered to you by the employer identified on the form. If your employer is not an Applicable Large  to your spouse; and minimum essential coverage offered to your dependent(s).  All 12  $  Form 1095-C, Part III, provides information about you and your family members who had certain health coverage (referred to  primary residence ZIP code.  REMOVE THESE EDGES FIRST FOLD, CREASE AND TEAR ALONG PERFORATION
                           1L. Individual coverage health reimbursement arrangement (HRA) offered to you only with affordability determined by using
                                                                     as “minimum essential coverage”) for some or all months during the year.
                                                                                  1N. Individual coverage HRA offered to you, spouse, and dependent(s) with affordability determined by using employee’s pri-
              Employer, it is not required to furnish you a Form 1095-C providing information about the health coverage it offered. In addi-  Months  If your employer provided you or a family member health coverage through an insured health plan or in another manner,  mary residence ZIP code.
              tion, if you, or any other individual who is offered health coverage because of their relationship to you (referred to here as  employee’s primary residence ZIP code.  Mar  $ $ $  For Privacy  you may receive information about the coverage separately on Form 1095-B, Health Coverage. Similarly, if you or a family  1O. Individual coverage HRA offered to you only using the employee’s primary employment site ZIP code affordability safe har-
                           1M. Individual coverage HRA offered to you and dependent(s) (not spouse) with affordability determined by using employee’s Jan
              family members), enrolled in your employer’s health plan and that plan is a type of plan referred to as a “self-insured” plan,
              Form 1095-C, Part III, provides information about you and your family members who had certain health coverage (referred to
                           primary residence ZIP code.
                                                                     member obtained minimum essential coverage from another source, such as a government-sponsored program, an individual
                                                                                  bor.
                                                                                  1P. Individual coverage HRA offered to you and dependent(s) (not spouse) using the employee’s primary employment site
              as “minimum essential coverage”) for some or all months during the year.
                           1N. Individual coverage HRA offered to you, spouse, and dependent(s) with affordability determined by using employee’s pri-
                                                                     market plan, or miscellaneous coverage designated by the Department of Health and Human Services, you may receive
                                                                                  ZIP code affordability safe harbor.
                           1O. Individual coverage HRA offered to you only using the employee’s primary employment site ZIP code affordability safe har- Feb
                                                                     information about that coverage on Form 1095-B. If you or a family member enrolled in a qualified health plan through a
                           mary residence ZIP code.
                                                   Act and
                                                                     Health Insurance Marketplace, the Health Insurance Marketplace will report information about that coverage on Form 1095-A,
                                                                                  1Q. Individual coverage HRA offered to you, spouse, and dependent(s) using the employee’s primary employment site ZIP
              If your employer provided you or a family member health coverage through an insured health plan or in another manner,
              you may receive information about the coverage separately on Form 1095-B, Health Coverage. Similarly, if you or a family
                                                                                  code affordability safe harbor.
                                                  Paperwork
              member obtained minimum essential coverage from another source, such as a government-sponsored program, an individual
                           bor.
            REMOVE THESE EDGES FIRST FOLD, CREASE AND TEAR ALONG PERFORATION  Health Insurance Marketplace, the Health Insurance Marketplace will report information about that coverage on Form 1095-A, H  ZIP code affordability safe harbor.  and the latest information.  Apr May June July Aug Sept  FOLD, CREASE AND TEAR ALONG PERFORATION  REMOVE THESE EDGES FIRST  $ $ $ $ $ $ $  see separate  REMOVE THESE EDGES FIRST REMOVE THESE EDGES FIRST FOLD, CREASE AND TEAR ALONG PERFORATION FOLD, CREASE AND TEAR ALONG PERFORATION  Additional information. For additional information about the tax provisions of the Affordable Care Act (ACA), the premium  spouse, and dependents.  FOLD, CREASE AND TEAR ALONG PERFORATION  FOLD, CREASE AND TEAR ALONG PERFORATION  REMOVE THESE EDGES FIRST  REMOVE THESE EDGES FIRST
                            Do not attach to your tax return. Keep for your records.
                                                                     Health Insurance Marketplace Statement.
                           1P. Individual coverage HRA offered to you and dependent(s) (not spouse) using the employee’s primary employment site
                                                  Reduction
                                                                                  1R. Individual coverage HRA that is NOT affordable offered to you; employee and spouse or dependent(s); or employee,
              market plan, or miscellaneous coverage designated by the Department of Health and Human Services, you may receive
                           spouse, and dependents. Go to www.irs.gov/Form1095C for instructions
                           1Q. Individual coverage HRA offered to you, spouse, and dependent(s) using the employee’s primary employment site ZIP
                                                  Act Notice,
              information about that coverage on Form 1095-B. If you or a family member enrolled in a qualified health plan through a
                                                                       Employers are required to furnish Form 1095-C only to the employee. As the recipient of this Form 1095-C,
                                                                                  1S. Individual coverage HRA offered to an individual who was not a full-time employee.
                                                                                  1T. Individual coverage HRA offered to employee and spouse (no dependents) with affordability determined using employ-
                                                                       you should provide a copy to any family members covered under a self-insured employer-sponsored plan
                           code affordability safe harbor.
                                                                                  ee’s primary residence ZIP code.
              Health Insurance Marketplace Statement.
                           1R. Individual coverage HRA that is NOT affordable offered to you; employee and spouse or dependent(s); or employee,
                                                                       listed in Part III if they request it for their records.
                           EMPLOYEE’S  First name, middle name, last name, street address (including
                            apartment no.), city or town, state or province, country, ZIP or foreign postal code
                                                                                  1U. Individual coverage HRA offered to employee and spouse (no dependents) using employee’s primary employment site
                                                  instructions.
                                                                                  ZIP code affordability safe harbor.
                           1S. Individual coverage HRA offered to an individual who was not a full-time employee.
                Employers are required to furnish Form 1095-C only to the employee. As the recipient of this Form 1095-C,
                                                                                  1V. Reserved for future use.
                you should provide a copy to any family members covered under a self-insured employer-sponsored plan
                           1T. Individual coverage HRA offered to employee and spouse (no dependents) with affordability determined using employ-
                                                                                  1W. Reserved for future use.
                           ee’s primary residence ZIP code.
                                                                                  1X. Reserved for future use.
                                                                     tax credit, and the employer shared responsibility provisions, visit www.irs.gov/ACA or call the IRS Healthcare Hotline for
                listed in Part III if they request it for their records.
                                                                     ACA questions (800-919-0452).
                           1U. Individual coverage HRA offered to employee and spouse (no dependents) using employee’s primary employment site
                           ZIP code affordability safe harbor.
                                                                     Part I. Employee
                                                                                  1Y. Reserved for future use.
                                                                                  1Z. Reserved for future use.
                           1V. Reserved for future use.
                                                                     Lines 1–6. Part I, lines 1 through 6, reports information about you, the employee.
              Additional information. For additional information about the tax provisions of the Affordable Care Act (ACA), the premium
                                                                                  Line 15. This line reports the employee required contribution, which is the monthly cost to you for the lowest cost self-only
              tax credit, and the employer shared responsibility provisions, visit www.irs.gov/ACA or call the IRS Healthcare Hotline for
                           1W. Reserved for future use.
                                                  Department of the
                                                                     Line 2. This is your social security number (SSN). For your protection, this form may show only the last four digits of your
                                                                                  minimum essential coverage providing minimum value that your employer offered you. For an individual coverage HRA, the
                           1X. Reserved for future use.
              ACA questions (800-919-0452).
                                                                     SSN. However, the employer is required to report your complete SSN to the IRS.
                                                                                  employee required contribution is the excess of the monthly premium based on the employee’s applicable age for the appli-
                           1Y. Reserved for future use.
                                                                     Part I. Applicable Large Employer Member (Employer)
              Part I. Employee
              Lines 1–6. Part I, lines 1 through 6, reports information about you, the employee.
                                                                                  HRA amount divided by 12). See the Instructions for Forms 1094-C and 1095-C for more details. The amount reported on
                           Line 15. This line reports the employee required contribution, which is the monthly cost to you for the lowest cost self-only
              Line 2. This is your social security number (SSN). For your protection, this form may show only the last four digits of your
                                                                     Line 10. This line includes a telephone number for the person whom you may call if you have questions about the informa-
              SSN. However, the employer is required to report your complete SSN to the IRS.
                                                                     tion reported on the form or to report errors in the information on the form and ask that they be corrected.
                                                                                  line 15 may not be the amount you paid for coverage if, for example, you chose to enroll in more expensive coverage such
                           APPLICABLE LARGE EMPLOYER’S
                                 number (SSN)
                           minimum essential coverage providing minimum value that your employer offered you. For an individual coverage HRA, the
                                                                                  as family coverage. Line 15 will show an amount only if code 1B, 1C, 1D, 1E, 1J, 1K, 1L, 1M, 1N, 1O, 1P, 1Q, 1T, or 1U is
                           employee required contribution is the excess of the monthly premium based on the employee’s applicable age for the appli-
                                 If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.
                                                                     Part II. Employer Offer of Coverage, Lines 14–17
                           cable lowest cost silver plan over the monthly individual coverage HRA amount (generally, the annual individual coverage
                           identification number (EIN)
              Part I. Applicable Large Employer Member (Employer)
                                                                                  entered on line 14. If you were offered coverage but there is no cost to you for the coverage, this line will report “0.00” for the
              Lines 7–13. Part I, lines 7 through 13, reports information about your employer.
                                                                     Line 14. The codes listed below for line 14 describe the coverage that your employer offered to you and your spouse and
                                                                                  amount. For more information, including on how your eligibility for other healthcare arrangements might affect the amount
                           HRA amount divided by 12). See the Instructions for Forms 1094-C and 1095-C for more details. The amount reported on
                                                                     dependent(s), if any. (If you received an offer of coverage through a multiemployer plan due to your membership in a union,
              Line 10. This line includes a telephone number for the person whom you may call if you have questions about the informa-  1Z. Reserved for future use.  EMPLOYEE’S social security  Oct Nov Dec  $ $  (e) Months of coverage  Treasury -- IRS  Lines 7–13. Part I, lines 7 through 13, reports information about your employer.  cable lowest cost silver plan over the monthly individual coverage HRA amount (generally, the annual individual coverage  TEAR AT THIS PERFORATION  TO OPEN, FOLD, AND
                                                                                  reported on line 15, visit IRS.gov.
                                                                     that offer may not be shown on line 14.) The information on line 14 relates to eligibility for coverage subsidized by the premi-
                           line 15 may not be the amount you paid for coverage if, for example, you chose to enroll in more expensive coverage such
              tion reported on the form or to report errors in the information on the form and ask that they be corrected.  as family coverage. Line 15 will show an amount only if code 1B, 1C, 1D, 1E, 1J, 1K, 1L, 1M, 1N, 1O, 1P, 1Q, 1T, or 1U is  (d)  Line 16. This code provides the IRS information to administer the employer shared responsibility provisions. Other than a
              Part II. Employer Offer of Coverage, Lines 14–17  entered on line 14. If you were offered coverage but there is no cost to you for the coverage, this line will report “0.00” for the  all 12 mos. Jan Feb Mar AprMay June July Aug SeptOct Nov Dec  um tax credit for you, your spouse, and dependent(s). For more information about the premium tax credit, see Pub. 974.  code 2C, which reflects your enrollment in your employer’s coverage, none of this information affects your eligibility for the
              Line 14. The codes listed below for line 14 describe the coverage that your employer offered to you and your spouse and    55447  amount. For more information, including on how your eligibility for other healthcare arrangements might affect the amount  (c) DOB (If SSN or other   Covered  1A. Minimum essential coverage providing minimum value offered to you with an employee required contribution for self-only  premium tax credit.  8402635
                                                                     coverage equal to or less than 9.5% (as adjusted) of the 48 contiguous states single federal poverty line and minimum essen-
                           Part III
              dependent(s), if any. (If you received an offer of coverage through a multiemployer plan due to your membership in a union,  reported on line 15, visit IRS.gov. Covered Individuals  TIN is not available)  tial coverage offered to your spouse and dependent(s) (referred to here as a Qualifying Offer). This code may be used to  Line 17. This line reports the applicable ZIP code your employer used for determining affordability if you were offered an indi-
                                   (b) SSN or other TIN
              that offer may not be shown on line 14.) The information on line 14 relates to eligibility for coverage subsidized by the premi-  Line 16. This code provides the IRS information to administer the employer shared responsibility provisions. Other than a  report for specific months for which a Qualifying Offer was made, even if you did not receive a Qualifying Offer for all 12  vidual coverage HRA. If code 1L, 1M, 1N, or 1T was used on line 14, this will be your primary residence location. If code 1O,
                             (a) Name of covered individual(s)

              um tax credit for you, your spouse, and dependent(s). For more information about the premium tax credit, see Pub. 974.  1P, 1Q, or 1U was used on line 14, this will be your primary employment site. For more information about individual coverage
              1A. Minimum essential coverage providing minimum value offered to you with an employee required contribution for self-only  code 2C, which reflects your enrollment in your employer’s coverage, none of this information affects your eligibility for the  months of the calendar year. For information on the adjustment of the 9.5%, visit IRS.gov.
              coverage equal to or less than 9.5% (as adjusted) of the 48 contiguous states single federal poverty line and minimum essen-  premium tax credit.  First name, middle initial, last name   1B. Minimum essential coverage providing minimum value offered to you and minimum essential coverage NOT offered to  HRAs, visit IRS.gov.
                                                                     your spouse or dependent(s).
                                                                                  Part III. Covered Individuals, Lines 18–35
                           Line 17. This line reports the applicable ZIP code your employer used for determining affordability if you were offered an indi-
              tial coverage offered to your spouse and dependent(s) (referred to here as a Qualifying Offer). This code may be used to  vidual coverage HRA. If code 1L, 1M, 1N, or 1T was used on line 14, this will be your primary residence location. If code 1O,  1C. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your  Part III reports the name, SSN (or TIN for covered individuals other than the employee listed in Part I), and coverage informa-
              report for specific months for which a Qualifying Offer was made, even if you did not receive a Qualifying Offer for all 12  tion about each individual (including any full-time employee and non-full-time employee, and any employee’s family members)
              months of the calendar year. For information on the adjustment of the 9.5%, visit IRS.gov.  1P, 1Q, or 1U was used on line 14, this will be your primary employment site. For more information about individual coverage  dependent(s) but NOT your spouse.
              1B. Minimum essential coverage providing minimum value offered to you and minimum essential coverage NOT offered to  HRAs, visit IRS.gov.  1D. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your  covered under the employer’s health plan, if the plan is “self-insured.” A date of birth will be entered in column (c) only if an
              your spouse or dependent(s).  Part III. Covered Individuals, Lines 18–35  spouse but NOT your dependent(s).  SSN (or TIN for covered individuals other than the employee listed in Part I) is not entered in column (b). Column (d) will be
                           18
                                                                                  checked if the individual was covered for at least one day in every month of the year. For individuals who were covered for
                                                                     1E. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your
              1C. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your  Part III reports the name, SSN (or TIN for covered individuals other than the employee listed in Part I), and coverage informa-  dependent(s) and spouse.  some but not all months, information will be entered in column (e) indicating the months for which these individuals were cov-
              dependent(s) but NOT your spouse.  tion about each individual (including any full-time employee and non-full-time employee, and any employee’s family members)  ered. If there are more than 18 covered individuals, additional copies of page 3 may be used.
                             8402798
              1D. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your  covered under the employer’s health plan, if the plan is “self-insured.” A date of birth will be entered in column (c) only if an
              spouse but NOT your dependent(s).  SSN (or TIN for covered individuals other than the employee listed in Part I) is not entered in column (b). Column (d) will be
              1E. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your  checked if the individual was covered for at least one day in every month of the year. For individuals who were covered for  DOUBLE POSTCARDS
                            19
              dependent(s) and spouse.  some but not all months, information will be entered in column (e) indicating the months for which these individuals were cov-
                           ered. If there are more than 18 covered individuals, additional copies of page 3 may be used.
                            20
                                                                                                                                                                                                     ARE GREAT FOR
                            21
                                                                                                                                                                                                         1099G’S
                            22
                                                                                                                  Patent Number US 7,975,904 B2
                            23
                            24
                            25
                                                                                       TXF 1095C-B
                            26
                            27                                                                                                               59416
                             28        5
                            TXF 1095C-PV  29 30                                                                                                                                                                            TO OPEN, FOLD, AND
                             31
                                                                                              D                                                                                                                           TEAR AT THIS PERFORATION
                             32                                                                                                              PSF4CN-BLANK
                                       E
                             33                     Form 1095-C
                             PSFEZ-BLANK-POP  34 35    (202 )                                     First-Class Mail
                                                                                                  Document Enclosed
                                         First-Class Mail                            SEE REVERSE SIDE FOR  Important Tax Return
                                         Important Tax Return                         OPENING INSTRUCTIONS
                                         Document Enclosed                                                                                  SEE REVERSE SIDE FOR OPENING INSTRUCTIONS
                             SEE REVERSE SIDE FOR  OPENING INSTRUCTIONS
                       TXF 1095C-PV                                            TXF 1095C-Blank
                                                                                                                                                  TXF 4CN-BLANK                                             PST DBPCD
            14” EZ-Fold - Employer- Provided Health                            14” EZ-Fold - Employer-
                  Insurance Offer and Coverage                                Provided Health Insurance                                        14” EZ-Fold Multi-Purpose                           8-1/2” x 12” V-Fold Multi-Purpose
               Printed Face, Part I & II print vertical                           Offer and Coverage                                          Pop Open - Blank - 4 Corner                               Blank Double Postcard
                 Instructions on Backer - Simplex                                     Blank Face                                              Blank Backer - Simplex or Duplex                             100# Tag - Duplex
                                                                          Instructions on Backer - Simplex
                                     REMOVE SIDE EDGES FIRST
                                     REMOVE SIDE EDGES FIRST
                                  SLIDE FINGER BETWEEN FRONT & MIDDLE PANEL TO OPEN
                                  SLIDE FINGER BETWEEN FRONT & MIDDLE PANEL TO OPEN
                           Form 1095-C (2024)      Page 2
                           Instructions for Recipient  1F. Minimum essential coverage NOT providing minimum value offered to you, or you and your spouse or dependent(s), or
                           You are receiving this Form 1095-C because your employer is an Applicable Large Employer subject to the employer shared  you, your spouse, and dependent(s).
                           responsibility provisions in the Affordable Care Act. This Form 1095-C includes information about the health insurance cover-  1G. You were NOT a full-time employee for any month of the calendar year but were enrolled in self-insured employer-spon-
                           age offered to you by your employer. Form 1095-C, Part II, includes information about the coverage, if any, your employer  sored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box or in the
                                        separate monthly boxes for all 12 calendar months on line 14.
                           offered to you and your spouse and dependent(s). If you purchased health insurance coverage through the Health Insurance  1H. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum
                           Marketplace and wish to claim the premium tax credit, this information will assist you in determining whether you are eligible.
                           If you or your family members are eligible for certain types of minimum essential coverage, you may not be eligible for the  essential coverage).
                           premium tax credit. For more information about the premium tax credit, see Pub. 974, Premium Tax Credit (PTC).  1I. Reserved for future use.
                           You may receive multiple Forms 1095-C if you had multiple employers during the year that were Applicable Large  1J. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered to
                           Employers (for example, you left employment with one Applicable Large Employer and began a new position of employment  your spouse; and minimum essential coverage NOT offered to your dependent(s).
                           with another Applicable Large Employer). In that situation, each Form 1095-C would have information only about the health  1K. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered
                           insurance coverage offered to you by the employer identified on the form. If your employer is not an Applicable Large  to your spouse; and minimum essential coverage offered to your dependent(s).
                           Employer, it is not required to furnish you a Form 1095-C providing information about the health coverage it offered. In addi-  1L. Individual coverage health reimbursement arrangement (HRA) offered to you only with affordability determined by using
                                        employee’s primary residence ZIP code.
                           tion, if you, or any other individual who is offered health coverage because of their relationship to you (referred to here as
                                        1M. Individual coverage HRA offered to you and dependent(s) (not spouse) with affordability determined by using employee’s
                           family members), enrolled in your employer’s health plan and that plan is a type of plan referred to as a “self-insured” plan,
                                        primary residence ZIP code.
                           Form 1095-C, Part III, provides information about you and your family members who had certain health coverage (referred to
                                        1N. Individual coverage HRA offered to you, spouse, and dependent(s) with affordability determined by using employee’s pri-
                           as “minimum essential coverage”) for some or all months during the year.
                           If your employer provided you or a family member health coverage through an insured health plan or in another manner,
                                        mary residence ZIP code.
                           you may receive information about the coverage separately on Form 1095-B, Health Coverage. Similarly, if you or a family
                                        1O. Individual coverage HRA offered to you only using the employee’s primary employment site ZIP code affordability safe har-
                                        bor.
                           member obtained minimum essential coverage from another source, such as a government-sponsored program, an individual
                         REMOVE THESE EDGES FIRST REMOVE THESE EDGES FIRST FOLD, CREASE AND TEAR ALONG PERFORATION FOLD, CREASE AND TEAR ALONG PERFORATION  market plan, or miscellaneous coverage designated by the Department of Health and Human Services, you may receive  1P. Individual coverage HRA offered to you and dependent(s) (not spouse) using the employee’s primary employment site  FOLD, CREASE AND TEAR ALONG PERFORATION  FOLD, CREASE AND TEAR ALONG PERFORATION  REMOVE THESE EDGES FIRST  REMOVE THESE EDGES FIRST  SLIDE FINGER BETWEEN FRONT & MIDDLE PANEL TO OPEN  Avoid Troublesome High Cost Mailings
                                        ZIP code affordability safe harbor.
                           information about that coverage on Form 1095-B. If you or a family member enrolled in a qualified health plan through a
                           Health Insurance Marketplace, the Health Insurance Marketplace will report information about that coverage on Form 1095-A,
                                        1Q. Individual coverage HRA offered to you, spouse, and dependent(s) using the employee’s primary employment site ZIP
                                        code affordability safe harbor.
                           Health Insurance Marketplace Statement.
                                        1R. Individual coverage HRA that is NOT affordable offered to you; employee and spouse or dependent(s); or employee,
                                        spouse, and dependents.
                             Employers are required to furnish Form 1095-C only to the employee. As the recipient of this Form 1095-C,
                                        1S. Individual coverage HRA offered to an individual who was not a full-time employee.
                                        1T. Individual coverage HRA offered to employee and spouse (no dependents) with affordability determined using employ-
                             you should provide a copy to any family members covered under a self-insured employer-sponsored plan
                                        ee’s primary residence ZIP code.
                             listed in Part III if they request it for their records.
                                        1U. Individual coverage HRA offered to employee and spouse (no dependents) using employee’s primary employment site
                                            Form 1095-C
                                                                                                     REMOVE SIDE EDGES FIRST
                              600120
                                        1V. Reserved for future use.G
                                        ZIP code affordability safe harbor.
                           Additional information. For additional information about the tax provisions of the Affordable Care Act (ACA), the premium
                           tax credit, and the employer shared responsibility provisions, visit www.irs.gov/ACA or call the IRS Healthcare Hotline for
                                        1W. Reserved for future use.
                           Part I. Employee 202
                                            Internal Revenue Service
                           ACA questions (800-919-0452).
                                        1Y. Reserved for future use.
                                            Part I
            Employer-Provided Health Insurance Offer and Coverage   VOID CORRECTED  OMB No. 1545-2251  1X. Reserved for future use.  Department of the Treasury   Employer-Provided Health Insurance Offer and Coverage   VOID  OMB No. 1545-2251 600120  Instructions for Recipient  If you or another family member received health insurance coverage Page 2
                                                                                            Form 1095-B (2024)
                                        1Z. Reserved for future use.
                                             Employee
                           Lines 1–6. Part I, lines 1 through 6, reports information about you, the employee.
                                        Line 15. This line reports the employee required contribution, which is the monthly cost to you for the lowest cost self-only
                           Line 2. This is your social security number (SSN). For your protection, this form may show only the last four digits of your
                                                  ▶  Do not attach to your tax return. Keep for your records.
               ▼ Do not attach to your tax return. Keep for your records.
                                        minimum essential coverage providing minimum value that your employer offered you. For an individual coverage HRA, the
                     Applicable Large Employer Member (Employer)
                                                                                                         through a Health Insurance Marketplace (also known as an Exchange),
                                                 ▶  Go to www.irs.gov/Form1095C for instructions and the latest information.
                           SSN. However, the employer is required to report your complete SSN to the IRS.
                             8  Employer identification number (EIN)
        Form 1095-C  ▼ Go to www.irs.gov/Form1095C for instructions and the latest information.   Part I. Applicable Large Employer Member (Employer)  cable lowest cost silver plan over the monthly individual coverage HRA amount (generally, the annual individual coverage   7  Name of employer   CORRECTED  2 20 02   This Form 1095-B provides information about the individuals in your tax family (your-  that coverage will generally be reported on a Form 1095-A rather than a
                                            1  Name of employee (first name, middle initial, last name)
                                        employee required contribution is the excess of the monthly premium based on the employee’s applicable age for the appli-  2  Social security number (SSN)
                                        HRA amount divided by 12). See the Instructions for Forms 1094-C and 1095-C for more details. The amount reported on
                           Lines 7–13. Part I, lines 7 through 13, reports information about your employer.
                                                                                            self, spouse, and dependents) who had certain health coverage (referred to as “mini-
                                                                                            mum essential coverage”) for some or all months during the year. Minimum essential
                                                                                                         Form 1095-B. If you or another family member received employer-
                           Line 10. This line includes a telephone number for the person whom you may call if you have questions about the informa-
                                             3  Street address (including apartment no.)
                                        line 15 may not be the amount you paid for coverage if, for example, you chose to enroll in more expensive coverage such
                            10 Contact telephone number
        Department of the Treasury    2  Social security number (SSN)   7  Name of employer   tion reported on the form or to report errors in the information on the form and ask that they be corrected.  as family coverage. Line 15 will show an amount only if code 1B, 1C, 1D, 1E, 1J, 1K, 1L, 1M, 1N, 1O, 1P, 1Q, 1T, or 1U is   8   coverage includes government-sponsored programs, eligible employer-sponsored  (Part III) rather than a Form 1095-B. For more information, see
                                                         Applicable Large Employer Member (Employer)
                                                                                                         sponsored coverage, that coverage may be reported on a Form 1095-C
                           Part II. Employer Offer of Coverage, Lines 14–17
        Internal Revenue Service
                                        entered on line 14. If you were offered coverage but there is no cost to you for the coverage, this line will report “0.00” for the
                                          J
                                                                                            plans, individual market plans, and other coverage the Department of Health and
                            13 Country and ZIP or foreign postal code
                           Line 14. The codes listed below for line 14 describe the coverage that your employer offered to you and your spouse and
        Part I
         Employee
          1  Name of employee (first name, middle initial, last name)   9  Street address (including room or suite no.)   dependent(s), if any. (If you received an offer of coverage through a multiemployer plan due to your membership in a union,  reported on line 15, visit IRS.gov.    4  City or town  5  State or province   9  Street address (including room or suite no.)   10 Contact telephone number  1  Human Services designates as minimum essential coverage.  www.irs.gov/Affordable-Care-Act/Questions-and-Answers-About-Health-Care-
                                        amount. For more information, including on how your eligibility for other healthcare arrangements might affect the amount
                                                                                                        Information-Forms-for-Individuals.
                           that offer may not be shown on line 14.) The information on line 14 relates to eligibility for coverage subsidized by the premi-
                        12  State or province
                                                                                            If individuals in your tax family are eligible for certain types of minimum essential
                                        code 2C, which reflects your enrollment in your employer’s coverage, none of this information affects your eligibility for the
                                           Part II
                           um tax credit for you, your spouse, and dependent(s). For more information about the premium tax credit, see Pub. 974.
          3  Street address (including apartment no.)    6 Country and ZIP or foreign postal code 11 City or town  1A. Minimum essential coverage providing minimum value offered to you with an employee required contribution for self-only  premium tax credit.  Employee Offer of Coverage  coverage, you may not be eligible for the premium tax credit. For more information on  Line 9. Reserved.
                                        Line 16. This code provides the IRS information to administer the employer shared responsibility provisions. Other than a  6 Country and ZIP or foreign postal code 11 City or town
                           coverage equal to or less than 9.5% (as adjusted) of the 48 contiguous states single federal poverty line and minimum essen-
                                              All 12 Months
       F    5  State or province  Plan Start Month (Enter 2-digit number): Nov  Dec  vidual coverage HRA. If code 1L, 1M, 1N, or 1T was used on line 14, this will be your primary residence location. If code 1O, Mar  12  State or province  Part II. Information About Certain Employer-Sponsored Coverage, lines 10–15. If
                           tial coverage offered to your spouse and dependent(s) (referred to here as a Qualifying Offer). This code may be used to
                                                                                            the premium tax credit, see Pub. 974, Premium Tax Credit (PTC).
                                        Line 17. This line reports the applicable ZIP code your employer used for determining affordability if you were offered an indi-
                                                Jan
                                           14  Offer of
                           report for specific months for which a Qualifying Offer was made, even if you did not receive a Qualifying Offer for all 12
                                                 Feb
                                        1P, 1Q, or 1U was used on line 14, this will be your primary employment site. For more information about individual coverage
          4  City or town  Employee’s Age on January 1  June  July  Aug  Sept  months of the calendar year. For information on the adjustment of the 9.5%, visit IRS.gov.  HRAs, visit IRS.gov.  Coverage (enter   Employee’s Age on January 1 June  July  Plan Start Month (enter 2-digit number):  Providers of minimum essential coverage are required to furnish only one  you had employer-sponsored health coverage, this part may provide information about
                                                     Apr
                                                               13 Country and ZIP or foreign postal code
                            Oct
                                           required code)
                           1B. Minimum essential coverage providing minimum value offered to you and minimum essential coverage NOT offered to
                                                      May
                           your spouse or dependent(s).
                                                                                                        the employer sponsoring the coverage. This part may show only the last four digits of
                                        Part III. Covered Individuals, Lines 18–35
                                                                                             Form 1095-B for all individuals whose coverage is reported on that form.
                                           15  Employee
                                                                                             As the recipient of this Form 1095-B, you should provide a copy to other
                                                           Aug
         Employee Offer of Coverage  Mar  Apr  May  dependent(s) but NOT your spouse.  tion about each individual (including any full-time employee and non-full-time employee, and any employee’s family members)  Sept  Oct  Nov  individuals covered under the policy if they request it for their records.  the employer’s EIN. This part may also be left blank, even if you had employer-spon-
                                        Part III reports the name, SSN (or TIN for covered individuals other than the employee listed in Part I), and coverage informa-
                           1C. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your
                                           Required
                                           Contribution (see
        Part II  Jan  Feb  1D. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your  covered under the employer’s health plan, if the plan is “self-insured.” A date of birth will be entered in column (c) only if an  Dec  sored health coverage. If this part is blank, you do not need to fill in the information or
                                           instructions)
                                             $
                               $
                                        SSN (or TIN for covered individuals other than the employee listed in Part I) is not entered in column (b). Column (d) will be
          All 12 Months    1E. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your  checked if the individual was covered for at least one day in every month of the year. For individuals who were covered for  Additional information. For additional information about the tax provisions of the
                                               $
                           spouse but NOT your dependent(s).
                                                                                                        return it to your employer or other coverage provider.
                                                 $
                             $
                           $
                                                  $
                                           16 Section 4980H
        14  Offer of   $  $  $  dependent(s) and spouse.  some but not all months, information will be entered in column (e) indicating the months for which these individuals were cov-  $  $  $  Affordable Care Act (ACA) and the premium tax credit, see www.irs.gov/ACA or call  Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports informa-  FOLD, CREASE AND TEAR ALONG PERFORATION  REMOVE THESE EDGES FIRST
                                           Safe Harbor and
                                        ered. If there are more than 18 covered individuals, additional copies of page 3 may be used.
        Coverage (enter   $  $             code, if applicable)  $  $  $                  REMOVE THESE EDGES FIRST FOLD, CREASE AND TEAR ALONG PERFORATION  the IRS Healthcare Hotline for ACA questions (800-919-0452).  tion about the coverage provider (insurance company, employer providing self-insured
                                           Other Relief (enter
        required code)
        15  Employee   $  $  $  $           55447             $  $  $                       Part I. Responsible Individual, lines 1–9. Part I reports information about you and  coverage, government agency sponsoring coverage under a government program
                                                                                            the coverage.
        Required
        Contribution (see
                                                                                                        such as Medicaid or Medicare, or other coverage sponsor). Line 18 reports a tele-
        instructions)  $                   17 ZIP Code                                      Lines 2 and 3. Line 2 reports your social security number (SSN) or other taxpayer  phone number for the coverage provider that you can call if you have questions
        16  Section 4980H                   Covered Individuals                             the last four digits. However, the coverage provider is required to report your complete
                                           Part III
                                                                                                        about the information reported on the form.
                                                                                            identification number (TIN), if applicable. For your protection, this form may show only
        Safe Harbor and
        Other Relief (enter
        code, if applicable)   Nov  Dec                                                     SSN or other TIN, if applicable, to the IRS. Your date of birth will be entered on line 3  Part IV. Covered Individuals, lines 23–40. This part reports the name, SSN or other
                          (e) Months of Coverage
                                                                                            only if line 2 is blank.
                                                                                                        TIN, and coverage information for each covered individual. A date of birth will be
        17  ZIP Code If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee. Oct  First name, middle initial, last name  (b) SSN or other TIN    8402420  Line 8. This is the code for the type of coverage in which you or other covered individ-  entered in column (c) only if the SSN or other TIN is not entered in column (b). Column
                             Sept
                                            (a) Name of covered individual(s)
                            Aug
                          June


                           July
                        Apr
                    (d) Covered
                                                                                                        (d) will be checked if the individual was covered for at least 1 day in every month of
                         May
        Part III  Covered Individuals   (b) SSN or other TIN  (c) DOB (If SSN  all 12 months  Jan  Feb  Mar  (c) DOB (if SSN or other  (d) Covered         uals were enrolled. Only one letter will be entered on this line.  the year. For individuals who were covered for some but not all months, information  Total Pressure Seal Solution -
                  or other TIN is
                                                    TIN is not available)

                                                                                            A. Small Business Health Options Program (SHOP)
                                            If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.
                                                      all 12 months
          (a) Name of covered individual(s)  18        Jan  Feb  Mar  Apr  May  (e) Months of coverage   B. Employer-sponsored coverage  will be entered in column (e) indicating the months for which these individuals were
                  not available)
          First name, middle initial, last name
                                                                                                        covered. If there are more than eighteen covered individuals, see Part IV, Continuation
                                                             July
                                          8402871             Aug  Sept  Oct  Nov  Dec      C. Government-sponsored program  Sheet(s), for information about the additional covered individuals.
                                                            June
                                                                                            D. Individual market insurance
         18                                19                                               E. Multiemployer plan
                                                                                            F. Other designated minimum essential coverage

                                                                                            G. Individual coverage health reimbursement arrangement (HRA)
                                          20
         19
        8402719  20                       21
                                          22

         21
                                          23
         22
                                          24
         23
                                          25
         24                                                                                                                           Print, Image, Fold/Seal & Mail Service
                                  Patent Number US 7,975,904 B2
                                          26
         25
                                          27
         26
                                                    D
                                          28
          27
                                        TXF 1095C-CR  30
          28                              29                                TXF 1095B-B
          29
          30                             RAA #1607  For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.  41-0852411
         TXF 1095C-PH  31 32                                   Form 1095-C (202 )
          33                            PSFEZ-BLANK-POP
          34                    Form 1095-C (202 )
                         Cat. No. 60705M  FROM:                                         First-Class Mail
          For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.  Important Tax Return
          35
                                                                                        Document Enclosed
                                                                                                                    A
                      First-Class Mail
                      Important Tax Return                                  SEE REVERSE SIDE FOR  OPENING INSTRUCTIONS
                      Document Enclosed  SEE REVERSE SIDE FOR OPENING INSTRUCTIONS  Important Tax Document Enclosed  First-Class Mail
          SEE REVERSE SIDE FOR  OPENING INSTRUCTIONS                                                                                        Let our Mail                      • Accepted by the USPS
             TXF 1095C-PH or TXF 1095C-CR                                      TXF 1095B-Blank                                              Team make sure                    • Delivered to the Correct Addressee
             14” EZ-Fold - Employer-Provided Health                        14” EZ-Fold - Health Coverage                                    your mailing is:                  • Mailed at the Lowest Possible Rate!
                  Insurance Offer and Coverage                                        Blank Face
             Printed Face, Part I & II print horizontal                        Instructions on Backer -
                 Instructions on Backer - Simplex                                       Simplex
   1   2   3   4   5   6