1094-C Form Transmittal Of Employer-Provided Health Insurance Offer And Coverage Information Returns

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120116

1094-C

Transmittal of Employer-Provided Health Insurance Offer and

OMB No. 1545-2251

CORRECTED

Form

Coverage Information Returns

2015

Department of the Treasury

Information about Form 1094-C and its separate instructions is at

▶

Internal Revenue Service

Applicable Large Employer Member (ALE Member)

Part I

2 Employer identification number (EIN)

1 Name of ALE Member (Employer)

3 Street address (including room or suite no.)

4 City or town

5 State or province

6 Country and ZIP or foreign postal code

7 Name of person to contact

8 Contact telephone number

9 Name of Designated Government Entity (only if applicable)

10 Employer identification number (EIN)

11 Street address (including room or suite no.)

For Official Use Only

12 City or town

13 State or province

14 Country and ZIP or foreign postal code

15 Name of person to contact

16 Contact telephone number

17 Reserved .

18 Total number of Forms 1095-C submitted with this transmittal .

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19 Is this the authoritative transmittal for this ALE Member? If “Yes,” check the box and continue. If “No,” see instructions .

Part II

ALE Member Information

20 Total number of Forms 1095-C filed by and/or on behalf of ALE Member .

▶

21 Is ALE Member a member of an Aggregated ALE Group?

Yes

If “No,” do not complete Part IV.

22 Certifications of Eligibility (select all that apply):

A. Qualifying Offer Method

B. Qualifying Offer Method Transition Relief

C. Section 4980H Transition Relief

D. 98% Offer Method

Under penalties of perjury, I declare that I have examined this return and accompanying documents, and to the best of my knowledge and belief, they are true, correct, and complete.

Signature

Title

Date

1094-C

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 61571A

Form

(2015)