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)
