Fillable Printable Form 1094C
Fillable Printable Form 1094C
Form 1094C
120116
CORRECTED
Form1094-C
Department of the Treasury
Internal Revenue Service
Transmittal of Employer-Provided Health Insurance Offer and
Coverage Information Returns
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Information about Form 1094-C and its separate instructions is at www.irs.gov/form1094c
OMB No. 1545-2251
2015
Part I
Applicable Large Employer Member (ALE Member)
1 Name of ALE Member (Employer)
2 Employer identification number (EIN)
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.)
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
For Official Use Only
17 Reserved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
18 Total number of Forms 1095-C submitted with this transmittal . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Part II
ALE Member Information
19 Is this the authoritative transmittal for this ALE Member? If “Yes,” check the box and continue. If “No,” see instructions . . . . . . . . . . . . . . . .
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
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.
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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. 61571A
Form 1094-C (2015)
120216
Form 1094-C (2015) Page 2
Part III
ALE Member Information—Monthly
(a) Minimum Essential Coverage
Offer Indicator
Yes No
(b) Full-Time Employee Count
for ALE Member
(c) Total Employee Count
for ALE Member
(d) Aggregated
Group Indicator
(e) Section 4980H
Transition Relief Indicator
23 All 12 Months
24
Jan
25
Feb
26
Mar
27
Apr
28
May
29
June
30
July
31
Aug
32
Sept
33
Oct
34
Nov
35
Dec
Form 1094-C (2015)
120315
Form 1094-C (2015) Page 3
Part IV
Other ALE Members of Aggregated ALE Group
Enter the names and EINs of Other ALE Members of the Aggregated ALE Group (who were members at any time during the calendar year).
Name EIN
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Name EIN
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
Form 1094-C (2015)
