Transmittal of Health Coverage Information Returns
Department of the Treasury
Internal Revenue Service
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 . . . . . . . . . . . . . .
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.
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 61570P
Form 1094-B (2016)