Form 1095-B, Health Coverage Page 3
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Form 1095-B (2016)
Page
Name of responsible individual
Social security number (SSN or other TIN)
Date of birth (If SSN or other TIN is not available)
Part IV
Covered Individuals — Continuation Sheet
(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
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1095-B
Form
(2016)
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Parent category: Financial