Form 1095-C - Employer-Provided Health Insurance Offer And Coverage - 2015 Page 3

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Form 1095-C (2015)
Page
Name of employee
Social security number (SSN)
Part III
Covered Individuals — Continuation Sheet
(a) Name of covered individual(s)
(b) SSN
(c) DOB (If SSN is not
(d) Covered
(e) Months of coverage
available)
all 12 months
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
23
24
25
26
27
28
29
30
31
32
33
34
1095-C
Form
(2015)

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