Page 4 - Pressure Seal Tax Catalog

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
REMOVE SIDE EDGES FIRST
SLIDE FINGER BETWEEN FRONT & MIDDLE PANEL TO OPEN
SLIDE FINGER BETWEEN FRONT & MIDDLE PANEL TO OPEN Employer Form 1095-C (2025) 1F. Minimum essential coverage NOT providing minimum value offered to you, or you and your spouse or dependent(s), or Page 2
Instructions for Recipient
3
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).
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 (2025) 25 Form 1095–C 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 Employee’s Age 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
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-
essential coverage).
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).
state or province, country, ZIP or foreign postal code, and telephone no.
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
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
insurance coverage offered to you by the employer identified on the form. If your employer is not an Applicable Large
(enter code,
1I. Reserved for future use.
to your spouse; and minimum essential coverage offered to your dependent(s).
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 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
as “minimum essential coverage”) for some or all months during the year.
1L. Individual coverage health reimbursement arrangement (HRA) offered to you only with affordability determined by using
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
member obtained minimum essential coverage from another source, such as a government-sponsored program, an individual
bor.
primary residence ZIP code.
1P. Individual coverage HRA offered to you and dependent(s) (not spouse) using the employee’s primary employment site
market plan, or miscellaneous coverage designated by the Department of Health and Human Services, you may receive
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.
Act and
information about that coverage on Form 1095-B. If you or a family member enrolled in a qualified health plan through a
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
mary residence ZIP code.
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,
code affordability safe harbor.
Paperwork
you may receive information about the coverage separately on Form 1095-B, Health Coverage. Similarly, if you or a family
bor.
Health Insurance Marketplace Statement.
REMOVE THESE EDGES FIRST REMOVE THESE EDGES FIRST FOLD, CREASE AND TEAR ALONG PERFORATION FOLD, CREASE AND TEAR ALONG PERFORATION information about that coverage on Form 1095-B. If you or a family member enrolled in a qualified health plan through a ZIP code affordability safe harbor. and the latest information. Apr May June July Aug Sept FOLD, CREASE AND TEAR ALONG PERFORATION FOLD, CREASE AND TEAR ALONG PERFORATION REMOVE THESE EDGES FIRST 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
member obtained minimum essential coverage from another source, such as a government-sponsored program, an individual
Do not attach to your tax return. Keep for your records.
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
Employers are required to furnish Form 1095-C only to the employee. As the recipient of this Form 1095-C,
Act Notice,
1Q. Individual coverage HRA offered to you, spouse, and dependent(s) using the employee’s primary employment site ZIP
1S. Individual coverage HRA offered to an individual who was not a full-time employee.
you should provide a copy to any family members covered under a self-insured employer-sponsored plan
Health Insurance Marketplace, the Health Insurance Marketplace will report information about that coverage on Form 1095-A, P
1T. Individual coverage HRA offered to employee and spouse (no dependents) with affordability determined using employ-
Health Insurance Marketplace Statement.
code affordability safe harbor.
ee’s primary residence ZIP code.
1R. Individual coverage HRA that is NOT affordable offered to you; employee and spouse or dependent(s); or employee,
EMPLOYEE’S First name, middle name, last name, street address (including
listed in Part III if they request it for their records.
apartment no.), city or town, state or province, country, ZIP or foreign postal code
instructions.
1U. Individual coverage HRA offered to employee and spouse (no dependents) using employee’s primary employment site
1S. Individual coverage HRA offered to an individual who was not a full-time employee.
ZIP code affordability safe harbor.
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.
1T. Individual coverage HRA offered to employee and spouse (no dependents) with affordability determined using employ-
1W. Reserved for future use.
you should provide a copy to any family members covered under a self-insured employer-sponsored plan
listed in Part III if they request it for their records.
1X. Reserved for future use.
ee’s primary residence ZIP code.
tax credit, and the employer shared responsibility provisions, visit www.irs.gov/ACA or call the IRS Healthcare Hotline for
1U. Individual coverage HRA offered to employee and spouse (no dependents) using employee’s primary employment site
ACA questions (800-919-0452).
1Y. Reserved for future use.
ZIP code affordability safe harbor.
Part I. Employee
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
Department of the
1W. Reserved for future use.
minimum essential coverage providing minimum value that your employer offered you. For an individual coverage HRA, the
Line 2. This is your social security number (SSN). For your protection, this form may show only the last four digits of your
1X. Reserved for future use.
SSN. However, the employer is required to report your complete SSN to the IRS.
ACA questions (800-919-0452).
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. Employee
Part I. Applicable Large Employer Member (Employer)
HRA amount divided by 12). See the Instructions for Forms 1094-C and 1095-C for more details. The amount reported on
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
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.
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.
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
Part I. Applicable Large Employer Member (Employer)
cable lowest cost silver plan over the monthly individual coverage HRA amount (generally, the annual individual coverage
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
identification number (EIN)
amount. For more information, including on how your eligibility for other healthcare arrangements might affect the amount
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
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 Apr MayJune July Aug SeptOctNov 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 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. 8804074
coverage equal to or less than 9.5% (as adjusted) of the 48 contiguous states single federal poverty line and minimum essen-
Part III
(b) SSN or other TIN
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-
(a) Name of covered individual(s)
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,

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.
Part III. Covered Individuals, Lines 18–35
your spouse or dependent(s).
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
1E. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your
18
checked if the individual was covered for at least one day in every month of the year. For individuals who were covered for
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.
8804104
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.
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ARE GREAT FOR
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1099G’S
22
Patent Number US 7,975,904 B2
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25
TXF 1095C-B
26
27 59416
28
TXF 1095C-PV 29 30 TO OPEN, FOLD, AND
31
M TEAR AT THIS PERFORATION
32 PSF4CN-BLANK
M
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Form 1095-C
(2025)
34
35 Important Tax Return
First-Class Mail
First-Class Mail SEE REVERSE SIDE FOR Document Enclosed
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 (2025) 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
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.
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
information about that coverage on Form 1095-B. If you or a family member enrolled in a qualified health plan through a
ZIP code affordability safe harbor.
1Q. Individual coverage HRA offered to you, spouse, and dependent(s) using the employee’s primary employment site ZIP
Health Insurance Marketplace, the Health Insurance Marketplace will report information about that coverage on Form 1095-A,
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.
Form 1095-C
1U. Individual coverage HRA offered to employee and spouse (no dependents) using employee’s primary employment site
600120
REMOVE SIDE EDGES FIRST
ZIP code affordability safe harbor.
Additional information. For additional information about the tax provisions of the Affordable Care Act (ACA), the premium
1V. Reserved for future use.
1W. Reserved for future use.
tax credit, and the employer shared responsibility provisions, visit www.irs.gov/ACA or call the IRS Healthcare Hotline for
Part I. Employee 2025
Internal Revenue Service
ACA questions (800-919-0452).
Part I
1Y. Reserved for future use.
Form 1095-B (2025)
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 Tip: If you or another family member received health insurance coverage through a Page 2
Employee
1Z. Reserved for future use.
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.
minimum essential coverage providing minimum value that your employer offered you. For an individual coverage HRA, the
▼ Do not attach to your tax return. Keep for your records.
SSN. However, the employer is required to report your complete SSN to the IRS.
Applicable Large Employer Member (Employer)
▶ Go to www.irs.gov/Form1095C for instructions and the latest information.
1 Name of employee (first name, middle initial, last name)
Form 1095-C ▼ Go to www.irs.gov/Form1095C for instructions and the latest information. Part I. Applicable Large Employer Member (Employer) 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) 7 Name of employer CORRECTED 2 20 025 This Form 1095-B provides information about the individuals in your tax family Health Insurance Marketplace (also known as an Exchange), that coverage will
8 Employer identification number (EIN)
cable lowest cost silver plan over the monthly individual coverage HRA amount (generally, the annual individual coverage
(yourself, spouse, and dependents) who had certain health coverage (referred to as
Lines 7–13. Part I, lines 7 through 13, reports information about your employer.
HRA amount divided by 12). See the Instructions for Forms 1094-C and 1095-C for more details. The amount reported on
3 Street address (including apartment no.)
generally be reported on a Form 1095-A rather than a Form 1095-B. If you or another
“minimum essential coverage”) for some or all months during the year. Minimum
line 15 may not be the amount you paid for coverage if, for example, you chose to enroll in more expensive coverage such
Line 10. This line includes a telephone number for the person whom you may call if you have questions about the informa-
Applicable Large Employer Member (Employer)
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 essential coverage includes government-sponsored programs, eligible family member received employer-sponsored coverage, that coverage may be
10 Contact telephone number
Internal Revenue Service
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
R
reported on a Form 1095-C (Part III) rather than a Form 1095-B. For more information,
13 Country and ZIP or foreign postal code
Part I
Employee
amount. For more information, including on how your eligibility for other healthcare arrangements might affect the amount
Line 14. The codes listed below for line 14 describe the coverage that your employer offered to you and your spouse and
employer-sponsored plans, individual market plans, and other coverage the
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 V Department of Health and Human Services designates as minimum essential see www.irs.gov/Affordable-Care-Act/Questions-and-Answers-About-Health-Care-
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
coverage.
code 2C, which reflects your enrollment in your employer’s coverage, none of this information affects your eligibility for the
um tax credit for you, your spouse, and dependent(s). For more information about the premium tax credit, see Pub. 974.
Part II
If individuals in your tax family are eligible for certain types of minimum essential
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
tial coverage offered to your spouse and dependent(s) (referred to here as a Qualifying Offer). This code may be used to
O 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 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
report for specific months for which a Qualifying Offer was made, even if you did not receive a Qualifying Offer for all 12
14 Offer of
Feb
1P, 1Q, or 1U was used on line 14, this will be your primary employment site. For more information about individual coverage
Apr
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): Tip: Providers of minimum essential coverage are required to furnish only one Form Part II. Information About Certain Employer-Sponsored Coverage, lines 10–15. If
Oct
13 Country and ZIP or foreign postal code
1B. Minimum essential coverage providing minimum value offered to you and minimum essential coverage NOT offered to
required code)
May
you had employer-sponsored health coverage, this part may provide information about
your spouse or dependent(s).
Part III. Covered Individuals, Lines 18–35
Aug
1095-B for all individuals whose coverage is reported on that form. As the recipient of
the employer sponsoring the coverage. This part may show only the last four digits of
15 Employee
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 this Form 1095-B, you should provide a copy to other individuals covered under the the employer’s EIN. This part may also be left blank, even if you had
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-
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 policy if they request it for their records. employer-sponsored health coverage. If this part is blank, you do not need to fill in the
$
instructions)
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 information or return it to your employer or other coverage provider.
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
$
$
$
16 Section 4980H
$
ered. If there are more than 18 covered individuals, additional copies of page 3 may be used.
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- $ $ $ Additional information. For additional information about the tax provisions of the Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports FOLD, CREASE AND TEAR ALONG PERFORATION REMOVE THESE EDGES FIRST
Safe Harbor and
Coverage (enter $ $ code, if applicable) $ $ $ REMOVE THESE EDGES FIRST FOLD, CREASE AND TEAR ALONG PERFORATION Affordable Care Act (ACA) and the premium tax credit, see www.irs.gov/ACA or call information about the coverage provider (insurance company, employer providing
Other Relief (enter
required code)
the IRS Healthcare Hotline for ACA questions (800-919-0452).
15 Employee $ $ $ $ $ $ $ Part I. Responsible Individual, lines 1–9. Part I reports information about you and self-insured coverage, government agency sponsoring coverage under a government
Required
Contribution (see
program such as Medicaid or Medicare, or other coverage sponsor). Line 18 reports a
instructions) $ 17 ZIP Code the coverage. telephone number for the coverage provider that you can call if you have
Part III
Lines 2 and 3. Line 2 reports your social security number (SSN) or other taxpayer
16 Section 4980H Covered Individuals identification number (TIN), if applicable. For your protection, this form may show only questions about the information reported on the form.
Safe Harbor and
Other Relief (enter
code, if applicable) Nov Dec the last four digits. However, the coverage provider is required to report your complete Part IV. Covered Individuals, lines 23–40. This part reports the name, SSN or other
(e) Months of Coverage
SSN or other TIN, if applicable, to the IRS. Your date of birth will be entered on line 3
Sept
Aug
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 8804072 only if line 2 is blank. TIN, and coverage information for each covered individual. A date of birth will be
(a) Name of covered individual(s)
June
entered in column (c) only if the SSN or other TIN is not entered in column (b). Column

July

(d) Covered
May
Apr
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 Line 8. This is the code for the type of coverage in which you or other covered (d) will be checked if the individual was covered for at least 1 day in every month of Total Pressure Seal Solution -
or other TIN is

TIN is not available)
not available)
(a) Name of covered individual(s) 18 Jan Feb Mar Apr May (e) Months of coverage A. Small Business Health Options Program (SHOP) will be entered in column (e) indicating the months for which these individuals were
individuals were enrolled. Only one letter will be entered on this line.
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
the year. For individuals who were covered for some but not all months, information
First name, middle initial, last name
July
June
covered. If there are more than eighteen covered individuals, see Part IV, Continuation
8804106 Aug Sept Oct Nov Dec B. Employer-sponsored coverage Sheet(s), for information about the additional covered individuals.
C. Government-sponsored program
18 19 D. Individual market insurance
E. Multiemployer plan

F. Other designated minimum essential coverage
20 G. Individual coverage health reimbursement arrangement (HRA)
19
8804079 20 21
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Patent Number US 7,975,904 B2
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TXF 1095C-CR 30
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30 RAA #1607 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411
TXF 1095C-PH 31 32 Form 1095-C (2025)
33
34 Form 1095-C (2025)
Cat. No. 60705M FROM: First-Class Mail
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 10-1/2” Important Tax Return
35
Document Enclosed
U
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 Job # 8804106 - TXF 1095C-CR - Black Plate R 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