Designated Governmental Entity Form printable pdf download

Designated Governmental Entity Form

To give PEBA reporting responsibilities under Internal Revenue Code Section 6055 of Minimum

Essential Coverage

Under Internal Revenue Code (IRC) section 6055, a government employer may enter into a written

agreement with another governmental unit that designates the other governmental unit as the person

required to file the returns and furnish the required statements for some or all of the individuals receiving

minimum essential coverage under the same plan or arrangement.

Any employer who is statutorily required to participate in the State Health Plan (Governmental Employer)

may elect to designate the S.C. Public Employee Benefit Authority (PEBA) as its designated governmental

unit, agency or instrumentality (also known as a designated governmental entity) to fulfill any reporting

requirements for its former employees and their dependents (provided the former employees are retired or

otherwise terminated from employment for the entire year) under IRS section 6055. See

attachment A

for a

list of applicable employers. PEBA will not accept designation from employers whose participation in the

State Health Plan is optional.

The Governmental Employer listed below hereby designates PEBA as its designated governmental unit to

fulfill all reporting responsibilities under IRC section 6055 for former employees. This designation meets all

requirements under IRC section 6055(c)(ii) and is effective under all applicable laws. The Governmental

Employer must retain a signed and executed copy of the designation in its books and records. Once

executed, the Governmental Employer or PEBA may elect to revoke the designation by written notification at

least 60 days prior to furnishing the statements required by Section 6055 each year.

By signing this designation, the Governmental Employer and PEBA agree to the following:

1. The Governmental Employer is the person subject to the requirements of IRC section 6055;

2. PEBA agrees to report information on behalf of the Governmental Employer for purposes of IRC

section 6055 with respect to the Governmental Employer's former non-Medicare eligible employees

that were retired or otherwise terminated from employment for the entire reporting period and their

dependents;

3. PEBA meets the requirements of an appropriately designated governmental unit under IRC section

6055(c)(ii); and

4. PEBA will report on Form 1095-B.

Governmental Employer Information

Group Number: _________________________

Governmental Employer Name:

S.C. Public Employee Benefit Authority

______________________________________

Insurance Benefits

P.O. Box 11661

Governmental Employer EIN:

Columbia, SC 29211-1661

______________________________________

FEIN: 47-2655107

Governmental Employer Address:

______________________________________

PEBA's Authorized Signature:

Governmental Employer Contact:

______________________________________

Name: ________________________________

This _____ day of __________________, 2015

Title: __________________________________

Telephone: _____________________________

Authorized Signature:

If PEBA accepts the designation, PEBA will

______________________________________

return a signed copy of the form to the employer

for its file. This designation is not in effect until

This _____ day of __________________, 2015

the document has been signed by both the

employer and PEBA. If you have any questions,

Designated Governmental Unit Information

please contact PEBA’s BA Call Center at

803-734-2352.

I\4789799.5

Designated Governmental Entity Form

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