Fillable Printable Form 1094-B

Form 1094-B

110116

Form 1094-B

2016

Transmittal of Health Coverage Information Returns

Department of the Treasury

Internal Revenue Service

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Information about Form 1094-B and its separate instructions is at www.irs.gov/form1094b.

OMB No. 1545-2252

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

7 State or province 8 Country and ZIP or foreign postal code

9 Total number of Forms 1095-B submitted with this transmittal . . . . . . . . . . . . . .

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For Official Use Only

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.

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Signature

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Title

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Date

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 61570P

Form 1094-B (2016)