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 1/2”
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 Employer Form 1095-C (202 ) 1F. Minimum essential coverage NOT providing minimum value offered to you, or you and your spouse or dependent(s), or Page 2
SLIDE FINGER BETWEEN FRONT & MIDDLE PANEL TO OPEN
3
Instructions for Recipient
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 (202 ) 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 1/2”
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 Zip Code 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
For more information about the premium tax credit, see Pub. 974, Premium Tax Credit (PTC). You may receive multiple
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 Forms 1095-C if you had multiple employers during the year that were Applicable Large Employers (for example, you left 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 employment with one Applicable Large Employer and began a new position of employment with another 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 Contribution Harbor and Employer). In that situation, each Form 1095-C would have information only about the health insurance coverage offered to
1J. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered to Mo. (Enter
For more information about the premium tax credit, see Pub. 974, Premium Tax Credit (PTC). You may receive multiple essential coverage). APPLICABLE LARGE EMPLOYER’S name, street address, city or town, Coverage (see instructions) Other Relief Offer and you by the employer identified on the form. If your employer is not an Applicable Large Employer, it is not required to furnish 1K. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered 41884 PSDBPCD
(enter
(enter code,
you a Form 1095-C providing information about the health coverage it offered.
to your spouse; and minimum essential coverage offered to your dependent(s).
1I. Reserved for future use.
Forms 1095-C if you had multiple employers during the year that were Applicable Large Employers (for example, you left Part I required In addition, if you, or any other individual who is offered health coverage because of their relationship to you (referred to 1L. Individual coverage health reimbursement arrangement (HRA) offered to you only with affordability determined by using
employment with one Applicable Large Employer and began a new position of employment with another 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
Employer). In that situation, each Form 1095-C would have information only about the health insurance coverage offered to your spouse; and minimum essential coverage NOT offered to your dependent(s). here as family members), enrolled in your employer’s health plan and that plan is a type of plan referred to as a “self-insured” 1M. Individual coverage HRA offered to you and dependent(s) (not spouse) with affordability determined by using employee’s
you by the employer identified on the form. If your employer is not an Applicable Large Employer, it is not required to furnish 1K. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered plan, Form 1095-C, Part III, provides information about you and your family members who had certain health coverage
you a Form 1095-C providing information about the health coverage it offered. to your spouse; and minimum essential coverage offered to your dependent(s). All 12 $ (referred to as “minimum essential coverage”) for some or all months during the year. If you or your family members are eligi- primary residence ZIP code. REMOVE THESE EDGES FIRST FOLD, CREASE AND TEAR ALONG PERFORATION
ble for certain types of minimum essential coverage, you may not be eligible for the premium tax credit.
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-
In addition, if you, or any other individual who is offered health coverage because of their relationship to you (referred to 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.
here as family members), enrolled in your employer’s health plan and that plan is a type of plan referred to as a “self-insured” 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-
plan, Form 1095-C, Part III, provides information about you and your family members who had certain health coverage
1M. Individual coverage HRA offered to you and dependent(s) (not spouse) with affordability determined by using employee’s Jan
bor.
member obtained minimum essential coverage from another source, such as a government-sponsored program, an individual
primary residence ZIP code.
(referred to as “minimum essential coverage”) for some or all months during the year. If you or your family members are eligi-
market plan, or miscellaneous coverage designated by the Department of Health and Human Services, you may receive
ble for certain types of minimum essential coverage, you may not be eligible for the premium tax credit.
1P. Individual coverage HRA offered to you and dependent(s) (not spouse) using the employee’s primary employment site
1N. Individual coverage HRA offered to you, spouse, and dependent(s) with affordability determined by using employee’s pri-
mary residence ZIP code.
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
Act and
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,
If your employer provided you or a family member health coverage through an insured health plan or in another manner,
1Q. Individual coverage HRA offered to you, spouse, and dependent(s) using the employee’s primary employment site ZIP
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
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 spouse, and dependents. Go to www.irs.gov/Form1095C for instructions 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
Do not attach to your tax return. Keep for your records.
bor.
member obtained minimum essential coverage from another source, such as a government-sponsored program, an individual
Health Insurance Marketplace Statement.
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
1R. Individual coverage HRA that is NOT affordable offered to you; employee and spouse or dependent(s); or employee,
Reduction
ZIP code affordability safe harbor.
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.
Employers are required to furnish Form 1095-C only to the employee. As the recipient of this Form 1095-C,
Act Notice,
Health Insurance Marketplace, the Health Insurance Marketplace will report information about that coverage on Form 1095-A, 6
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.
and the latest information.
code affordability safe harbor.
Health Insurance Marketplace Statement.
EMPLOYEE’S First name, middle name, last name, street address (including
listed in Part III if they request it for their records.
1R. Individual coverage HRA that is NOT affordable offered to you; employee and spouse or dependent(s); or employee,
1U. Individual coverage HRA offered to employee and spouse (no dependents) using employee’s primary employment site
apartment no.), city or town, state or province, country, ZIP or foreign postal code
instructions.
ZIP code affordability safe harbor.
1S. Individual coverage HRA offered to an individual who was not a full-time employee.
1V. Reserved for future use.
Employers are required to furnish Form 1095-C only to the employee. As the recipient of this Form 1095-C,
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
1W. Reserved for future use.
1X. Reserved for future use.
listed in Part III if they request it for their records.
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).
Part I. Employee
1Y. Reserved for future use.
ZIP code affordability safe harbor.
1Z. Reserved for future use.
1V. Reserved for future use.
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
Lines 1–6. Part I, lines 1 through 6, reports information about you, the employee.
minimum essential coverage providing minimum value that your employer offered you. For an individual coverage HRA, the
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.
Line 2. This is your social security number (SSN). For your protection, this form may show only the last four digits of your
ACA questions (800-919-0452).
SSN. However, the employer is required to report your complete SSN to the IRS.
1X. Reserved for future use.
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)
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
HRA amount divided by 12). See the Instructions for Forms 1094-C and 1095-C for more details. The amount reported on
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-
APPLICABLE LARGE EMPLOYER’S
line 15 may not be the amount you paid for coverage if, for example, you chose to enroll in more expensive coverage such
SSN. However, the employer is required to report your complete SSN to the IRS.
number (SSN)
minimum essential coverage providing minimum value that your employer offered you. For an individual coverage HRA, the
tion reported on the form or to report errors in the information on the form and ask that they be corrected.
If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.
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-
identification number (EIN)
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
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
Part I. Applicable Large Employer Member (Employer)
Line 14. The codes listed below for line 14 describe the coverage that your employer offered to you and your spouse and
Lines 7–13. Part I, lines 7 through 13, reports information about your employer.
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
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
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.
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 MarAprMayJune July Aug Sept OctNov 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. For more information about the employer shared responsibility provisions, visit IRS.gov.
Part III
coverage equal to or less than 9.5% (as adjusted) of the 48 contiguous states single federal poverty line and minimum essen-
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
(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
First name, middle initial, last name
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. For more information about the employer shared responsibility provisions, visit IRS.gov. 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
Line 17. This line reports the applicable ZIP code your employer used for determining affordability if you were offered an indi-
your spouse or dependent(s).
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, see the additional covered individuals on Part III, Continuation Sheet(s).
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 5-1/4” 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, see the additional covered individuals on Part III, Continuation Sheet(s). 5/14”
20
ARE GREAT FOR
21
1099G’S
22
Patent Number US 7,975,904 B2
23
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25
TXF 1095C-B
26
27 59416
28
TXF 1095C-PV 29 30 TO OPEN, FOLD, AND
31
4 TEAR AT THIS PERFORATION
32 PSF4CN-BLANK
4
33
Form 1095-C 10-1/2”
(2023)
34
10-1/2”
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 (202 ) 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.
For more information about the premium tax credit, see Pub. 974, Premium Tax Credit (PTC). You may receive multiple essential coverage).
Forms 1095-C if you had multiple employers during the year that were Applicable Large Employers (for example, you left 1I. Reserved for future use.
employment with one Applicable Large Employer and began a new position of employment with another Applicable Large 1J. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered to
your spouse; and minimum essential coverage NOT offered to your dependent(s).
Employer). In that situation, each Form 1095-C would have information only about the health insurance coverage offered to
you by the employer identified on the form. If your employer is not an Applicable Large Employer, it is not required to furnish 1K. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered
you a Form 1095-C providing information about the health coverage it offered. to your spouse; and minimum essential coverage offered to your dependent(s).
1L. Individual coverage health reimbursement arrangement (HRA) offered to you only with affordability determined by using
In addition, if you, or any other individual who is offered health coverage because of their relationship to you (referred to
here as family members), enrolled in your employer’s health plan and that plan is a type of plan referred to as a “self-insured” 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
plan, Form 1095-C, Part III, provides information about you and your family members who had certain health coverage
primary residence ZIP code.
(referred to as “minimum essential coverage”) for some or all months during the year. If you or your family members are eligi-
1N. Individual coverage HRA offered to you, spouse, and dependent(s) with affordability determined by using employee’s pri-
ble for certain types of minimum essential coverage, you may not be eligible for the premium tax credit.
mary residence ZIP code.
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
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
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.
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-
ee’s primary residence ZIP code.
listed in Part III if they request it for their records.
REMOVE SIDE EDGES FIRST
Form 1095-C
1U. Individual coverage HRA offered to employee and spouse (no dependents) using employee’s primary employment site
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
ACA questions (800-919-0452).
Internal Revenue Service
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 (202 )
1Y. Reserved for future use.
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
▶ 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
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.
SSN. However, the employer is required to report your complete SSN to the IRS.
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.
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) 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
8 Employer identification number (EIN)
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)
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
self, spouse, and dependents) who had certain health coverage (referred to as “mini-
Line 10. This line includes a telephone number for the person whom you may call if you have questions about the informa-
Form 1095-B. If you or another family member received employer-
mum essential coverage”) for some or all months during the year. Minimum essential
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
Applicable Large Employer Member (Employer)
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
sponsored coverage, that coverage may be reported on a Form 1095-C
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
amount. For more information, including on how your eligibility for other healthcare arrangements might affect the amount
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-
Line 14. The codes listed below for line 14 describe the coverage that your employer offered to you and your spouse and
plans, individual market plans, and other coverage the Department of Health and
13 Country and ZIP or foreign postal code
Part I
Employee
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-
If individuals in your tax family are eligible for certain types of minimum essential
12 State or province
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
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. For more information about the employer shared responsibility provisions, visit IRS.gov. coverage, you may not be eligible for the premium tax credit. For more information on Line 9. Reserved.
Employee Offer of Coverage
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
Line 17. This line reports the applicable ZIP code your employer used for determining affordability if you were offered an indi-
5 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
the premium tax credit, see Pub. 974, Premium Tax Credit (PTC).
tial coverage offered to your spouse and dependent(s) (referred to here as a Qualifying Offer). This code may be used to
report for specific months for which a Qualifying Offer was made, even if you did not receive a Qualifying Offer for all 12
Jan
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
13 Country and ZIP or foreign postal code
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
Oct
Apr
1B. Minimum essential coverage providing minimum value offered to you and minimum essential coverage NOT offered to
May
required code)
Form 1095-B for all individuals whose coverage is reported on that form.
the employer sponsoring the coverage. This part may show only the last four digits of
your spouse or dependent(s).
Part III. Covered Individuals, Lines 18–35
1C. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your
Aug
As the recipient of this Form 1095-B, you should provide a copy to other
Part III reports the name, SSN (or TIN for covered individuals other than the employee listed in Part I), and coverage informa-
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 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-
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
$
return it to your employer or other coverage provider.
spouse but NOT your dependent(s).
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
$
$
16 Section 4980H
$
$
ered. If there are more than 18 covered individuals, see the additional covered individuals on Part III, Continuation Sheet(s).
Safe Harbor and
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
Other Relief (enter
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
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
Part III
identification number (TIN), if applicable. For your protection, this form may show only
16 Section 4980H Covered Individuals the last four digits. However, the coverage provider is required to report your complete
about the information reported on the form.
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
only if line 2 is blank.
(e) Months of Coverage
TIN, and coverage information for each covered individual. A date of birth will be
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 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
(a) Name of covered individual(s)
June

July

May
(d) will be checked if the individual was covered for at least 1 day in every month of
(d) Covered
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 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) 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
A. Small Business Health Options Program (SHOP)
all 12 months
not available)
If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.
First name, middle initial, last name
covered. If there are more than eighteen covered individuals, see Part IV, Continuation
July
June
Sept Oct C. Government-sponsored program Sheet(s), for information about the additional covered individuals.
Aug
Nov Dec
19 D. Individual market insurance
18 E. Multiemployer plan 5/14”
F. Other designated minimum essential coverage
G. Individual coverage health reimbursement arrangement (HRA)
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21
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21 5/14”
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24 Print, Image, Fold/Seal & Mail Service
Patent Number US 7,975,904 B2
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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 (2023)
33 PSFEZ-BLANK-POP 10-1/2”
34 Form 1095-C (2023)
Cat. No. 60705M 10-1/2” FROM:
Important Tax Return
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 10-1/2” Document Enclosed
35 First-Class Mail
2
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
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Insurance Offer and Coverage Blank Face
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