120116
1094-C
Transmittal of Employer-Provided Health Insurance Offer and
OMB No. 1545-2251
CORRECTED
Form
Coverage Information Returns
2015
Department of the Treasury
Information about Form 1094-C and its separate instructions is at
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Internal Revenue Service
Applicable Large Employer Member (ALE Member)
Part I
2 Employer identification number (EIN)
1 Name of ALE Member (Employer)
3 Street address (including room or suite no.)
4 City or town
5 State or province
6 Country and ZIP or foreign postal code
7 Name of person to contact
8 Contact telephone number
9 Name of Designated Government Entity (only if applicable)
10 Employer identification number (EIN)
11 Street address (including room or suite no.)
For Official Use Only
12 City or town
13 State or province
14 Country and ZIP or foreign postal code
15 Name of person to contact
16 Contact telephone number
17 Reserved .
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18 Total number of Forms 1095-C submitted with this transmittal .
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19 Is this the authoritative transmittal for this ALE Member? If “Yes,” check the box and continue. If “No,” see instructions .
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Part II
ALE Member Information
20 Total number of Forms 1095-C filed by and/or on behalf of ALE Member .
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21 Is ALE Member a member of an Aggregated ALE Group?
Yes
No
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If “No,” do not complete Part IV.
22 Certifications of Eligibility (select all that apply):
A. Qualifying Offer Method
B. Qualifying Offer Method Transition Relief
C. Section 4980H Transition Relief
D. 98% Offer Method
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-C
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 61571A
Form
(2015)