Form 1095-B, Health Coverage

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560116
1095-B
VOID
OMB No. 1545-2252
Health Coverage
Form
2016
Do not attach to your tax return. Keep for your records.
CORRECTED
Department of the Treasury
Internal Revenue Service
Information about Form 1095-B and its separate instructions is at
Part I
Responsible Individual
1
Name of responsible individual
2 Social security number (SSN or other TIN)
3 Date of birth (If SSN or other TIN is not available)
4 Street address (including apartment no.)
5
6
7
City or town
State or province
Country and ZIP or foreign postal code
9 Reserved
Enter letter identifying Origin of the Health Coverage (see instructions for codes):
.
.
.
8
Part II
Information about Certain Employer-Sponsored Coverage (see instructions)
10
Employer name
11
Employer identification number (EIN)
12 Street address (including room or suite no.)
13
City or town
14
State or province
15
Country and ZIP or foreign postal code
Part III
Issuer or Other Coverage Provider (see instructions)
16
Name
17
Employer identification number (EIN)
18
Contact telephone number
19 Street address (including room or suite no.)
20
City or town
21
State or province
22
Country and ZIP or foreign postal code
Part IV
Covered Individuals (Enter the information for each covered individual.)
(a) Name of covered individual(s)
(b) SSN or other TIN
(c) DOB (If SSN or other
(d) Covered
(e) Months of coverage
TIN is not available)
all 12 months
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
23
24
25
26
27
28
1095-B
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(2016)
Cat. No. 60704B

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