Form 8963 - Report Of Health Insurance Provider Information

Page 1 of 2

Report of Health Insurance

8963

OMB Number

Form

1545-2249

Provider Information

(Rev. February 2016)

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Information about Form 8963 and its separate instructions is at

Publicly Available

Department of the Treasury

Read the instructions before you complete Form 8963.

Information

Internal Revenue Service

Check only one box below (see instructions)

Corrected report

(see instructions)

Single-person covered entity:

Designated entity:

1 Single-person covered entity

2a Agent of an affiliated group

2b Other

Employer identification number (EIN)

Reporting year

Number of controlled group members included in

Schedule A (see instructions)

2016

Entity name

Entity name (continued)

Address (number and street). If you have a P.O. Box, see instructions.

Address (continued)

City, town, or post office (For foreign addresses, complete fields below - see instructions)

State

ZIP code

Foreign country name

Foreign province/state/county

Foreign postal code

Signature of Official Signing on Behalf of the Single-Person Covered Entity or Designated Entity

PART I

(Agent of an Affiliated Group, or Other Designated Entity) and Consent by the Designated Entity (if

applicable)

Under penalties of perjury, I declare that I have examined this report, including accompanying statements, and, to the best of my knowledge and belief, it

is true, correct, and complete. I further certify that I am an officer of the single-person covered entity or the designated entity, and that I am duly

authorized to sign this report on behalf of that covered entity.

If box 2a or 2b is checked, I also declare that the above named entity is the agent of an affiliated group or other designated entity (as per the

instructions). I understand that the designated entity will receive IRS communications relating to the fee imposed by ACA section 9010 and is to pay this

fee to the IRS on behalf of the controlled group. Each person that is a controlled group member at the end of the day on December 31, 2015, is jointly

and severally liable for this fee. I further declare that each controlled group member identified on this report consents to the choice of the designated

entity indicated on this report. Each person who is a controlled group member at the end of the day on December 31, 2015, and who would qualify as a

covered entity in 2016 if it were a single-person covered entity, is jointly and severally liable for any applicable penalty under ACA section 9010. (If the

designated entity is selected by the IRS, each controlled group member in this report is deemed to consent to the choice of designated entity.)

Signature of official

Date signed

Business phone number

Business fax number

Sign

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Here

Do not sign Form 8963

Printed name of signing official

Title of signing official

for electronically filed