Form 1095-B - Health Coverege - 2017
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1Health Coverage
OMB No. 1545-2252
1095-B
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VOID
Form
<:17
Department of the Treasury
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CORRECTED
Information about Form 1095-B and its separate instructions is at
Internal Revenue Service
Part I
Responsible Individual
1
Name of responsible individual
2
Social security no. (SSN or other TIN)
3
Date of birth (If SSN or TIN is not available)
JOHN M DOE SR
XXX-XX-0029
1983-03-22
4
Street address (including apartment no.)
5
City or town
6
State or province
7
Country and ZIP or foreign postal code
33 EAST 17 STREET APT 2101
NEW YORK
NY
10003-2005
8
9
Reserved
>
Enter letter identifying Origin of the Health Coverage (see instructions for codes). . . . . . .
B
Part II
Information about Certain Employer-Sponsored Coverage (see instructions)
Part II
10
Employer name
11 Employer identification number (EIN)
ACCOUNT ABILITY COMPLIANCE SOFTWARE
XX-XXX-9958
12
Street address (including room or suite no.)
13
City or town
14 State or province
15 Country and ZIP or foreign postal code
555 BROADHOLLOW RD STE 273
MELVILLE
NY
11747-5001
Part III
Issuer or Other Coverage Provider (see instructions)
16
Name
17 Employer identification number (EIN)
18 Contact telephone number
RENAISSANCE HEALTH CARE INC
11-4938827
888-302-0303
19
Street address (including room or suite no.)
20 City or town
21 State or province
22 Country and ZIP or foreign postal code
975 ALDER LANE SUITE 312
NEW YORK
NY
10023-1210
Part IV
Covered Individuals (Enter the information for each covered individual)
(e) Months of coverage
(c) DOB (If SSN or
(d) Covered
(a) Name of covered individual(s)
(b) SSN or other TIN
TIN is not available)
all 12 months
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
JOHN M DOE SR
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XXX-XX-0029
1983-03-22
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JANE DOE
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XXX-XX-9898
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JOHN DOE JR
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2017-09-04
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LENORE DOE
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XXX-XX-0394
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For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Do not attach to your tax return. Keep for your records.
Form 1095-B (2017)
Name of responsible individual
Social security number (SSN or other TIN)
Date of birth (If SSN or TIN is not available)
JOHN M DOE SR
XXX-XX-0029
1983-03-22
Part IV
Covered Individuals - Continuation Sheet
(e) Months of coverage
(c) DOB (If SSN or
(d) Covered
(a) Name of covered individual(s)
(b) SSN or other TIN
TIN is not available)
all 12 months
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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Form 1095-B (2017)
RENAISSANCE HEALTH CARE INC
FIRST-CLASS MAIL
975 ALDER LANE SUITE 312
U.S. POSTAGE
NEW YORK NY 10023-1210
PAID
MELVILLE, NEW YORK
PERMIT NO. 123456
TTAFTFADDADAAFDAAFFTDDADAFADFTFFAFTFDTFADFAFTAAADFTADFDTADTATTATF
JOHN M DOE SR
33 EAST 17 STREET APT 2101
NEW YORK NY 10003-2005
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