Form 1094-B - Transmittal Of Health Coverage Information Returns - 2017

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110116
1094-B
Transmittal of Health Coverage Information Returns
OMB No. 1545-2252
Form
2017
Department of the Treasury
Go to for instructions and the latest information.
Internal Revenue Service
1 Filer's name
2
Employer identification number (EIN)
3 Name of person to contact
4 Contact telephone number
5 Street address (including room or suite no.)
6 City or town
For Official Use Only
7 State or province
8 Country and ZIP or foreign postal code
Total number of Forms 1095-B submitted with this transmittal .
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9
Under penalties of perjury, I declare that I have examined this return and accompanying documents, and to the best of my knowledge and belief, they are true, correct, and complete.
Signature
Title
Date
1094-B
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(2017)
Cat. No. 61570P

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