Instructions For Recipient, Instructions For Forms 1094-B And 1095-B

Statements Furnished to Individuals, earlier, for

Column (e). If the individual was not covered for all

information on truncating the SSN or other TIN.

months check the applicable box(es) for the months in

which the individual was covered for at least one day. If

Line 3. Enter the responsible individual’s date of birth

there are more than six covered individuals, complete one

(MM/DD/YYYY) only if Line 2 is blank.

or more additional Forms 1095-B, Part I lines 1 through 7

Line 4-7. Enter the complete mailing address of the

and Part IV. Do not include these additional Forms 1095-B

responsible individual. If mail is not delivered to the street

in the count of forms submitted with Form 1094-B.

address and the responsible individual has a P.O. Box,

enter the box number instead of the street address.

Privacy Act and Paperwork Reduction Act Notice.

We ask for the information on these forms to carry out the

Line 8. Enter the letter identifying the origin of the policy.

Internal Revenue laws of the United States and the

A. Small Business Health Options Program (SHOP).

Patient Protection and Affordable Care Act. Our legal right

B. Employer-sponsored coverage.

to ask for the information on this form is Internal Revenue

C. Government-sponsored program.

Code 6055 and its regulations. We request it to confirm

D. Individual market insurance.

that insured individuals are covered by minimum essential

E. Multiemployer plan.

coverage and therefore are not liable for the individual

F. Miscellaneous minimum essential coverage.

shared responsibility payment. You are not required to

Line 9. For 2014, leave this line blank.

provide the information on these forms for 2014. If you do

not provide this information, we may be unable to

Part II—Employer Sponsored Coverage

determine whether covered individuals are liable for the

This part is completed only by issuers or carriers of

individual shared responsibility payment; providing false

insured group health plans, including coverage purchased

or fraudulent information may subject you to penalties. We

through the SHOP.

may disclose this information to the Department of Justice

for civil or criminal investigation, and to cities, states, and

Insurance companies entering codes A or B on

the District of Columbia for use in administering their tax

line 8 will complete Part II. Employers reporting

TIP

laws. We may also disclose this information to other

self-insured group health plan coverage on Form

countries under a tax treaty, to Federal and state agencies

1095-B enter code B on line 8, but do not complete Part II.

to enforce Federal nontax criminal laws, or to Federal law

If you entered code B for self-insured coverage, skip Part

enforcement and intelligence agencies to combat

II and go to Part III.

terrorism.

Lines 10–15. Enter the name, EIN, and complete mailing

You are not required to provide the information

address for the employer sponsoring the coverage. If mail

requested on a form that is subject to the Paperwork

is not delivered to the street address and the employer

Reduction Act unless the form displays a valid OMB

has a P.O. Box, enter the box number instead of the street

control number. Books or records relating to a form or its

address.

instructions must be retained as long as their contents

may become material in the administration of any Internal

Part III—Issuer or Other Coverage Provider

Revenue law. Generally, tax returns and return

information are confidential, as required by section 6103.

Lines 16-22. Enter the name, EIN, and complete mailing

address of the provider of the coverage. The provider of

The time needed to complete the following forms will

the coverage is the issuer or carrier of insured coverage,

vary depending on individual circumstances. The

sponsor of a self-insured employer plan, government

estimated average time is:

agency providing government-sponsored coverage, or

other entity. Enter on line 18 the telephone number the

individual seeking additional information may call to speak

Form 1094-B

10 min.

. . . . . . . . . . . . . . .

to a person.

Form 1095-B

1 min.

. . . . . . . . . . . . . . .

Part IV—Covered Individuals

Column (a). Enter the name of each covered individual.

If you have comments concerning the accuracy of

Column (b). Enter the nine-digit SSN for each covered

these time estimates or suggestions for making this form

individual (111-11-1111). Enter a TIN, rather than an SSN,

simpler, we would be happy to hear from you. You can

if the covered individual does not have an SSN. See

write to the Internal Revenue Service; Tax Forms and

Statements Furnished to Individuals, earlier, for

Publications Division; SE:W:CAR:MP:T, 1111 Constitution

information on truncating the SSN or other TIN.

Ave. NW, IR-6526, Washington, DC 20224. Do not send

the form to this office. Instead, see Where To File, earlier.

Column (c). Enter a date of birth (MM/DD/YYYY) for the

covered individual only if column (b) is blank.

Column (d). Check this box if the individual was covered

for at least one day per month for all 12 months of the

calendar year.

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Instructions for Forms 1094-B and 1095-B 2014

Instructions For Recipient, Instructions For Forms 1094-B And 1095-B - 2014 Page 5

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