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

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1094-B
OMB No. 1545-2252
Transmittal of Health Coverage Information Returns
Form
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Department of the Treasury
Information about Form 1094-B and its separate instructions is at
Internal Revenue Service
2 Employer id number (EIN)
1 Filer's name
RENAISSANCE HEALTH CARE INC
11-4938827
INFORMATION COPY
3 Name of person to contact
4 Contact telephone number
DO NOT FILE WITH IRS
FRANC MARCIANO
212-656-9875
5 Street address (including room or suite no.)
6 City or town
975 ALDER LANE SUITE 312
NEW YORK
For Official Use Only
7 State or province
8 Country, ZIP or foreign postal code
NY
10023-1210
9 Total number of Forms 1095-B submitted with this transmittal . . . .
>
1
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.
ADMINISTRATOR
>
>
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Title
Date
Signature
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form 1094-B (2017)

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