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Fillable Printable Form 1095b

What is a Form 1095b ?

Form 1095-B, used to claim certain information to the Internal Revenue Service, as well as taxpayers, regarding individuals covered by minimum essential coverage, for instance, minimum qualifying health insurance coverage, and, consequently, are not responsible for the individual shared responsibility payment. Download blank or editable online. Sign, fax and print with Handypdf.com right now!

Fillable Printable Form 1095b

What is a Form 1095b ?

Form 1095-B, used to claim certain information to the Internal Revenue Service, as well as taxpayers, regarding individuals covered by minimum essential coverage, for instance, minimum qualifying health insurance coverage, and, consequently, are not responsible for the individual shared responsibility payment. Download blank or editable online. Sign, fax and print with Handypdf.com right now!

Form 1095b

Form 1095b

Form
1095-B
2017
Department of the Treasury
Internal Revenue Service
Health Coverage
Do not attach to your tax return. Keep for your records.
Go to www.irs.gov/Form1095B for instructions and the latest information.
OMB No. 1545-2252
560116
VOID
CORRECTED
Part I
Responsible Individual
1 Name of responsible individual2
Social security number (SSN) or other TIN
3 Date of birth (if SSN or other TIN is not available)
4 Street address (including apartment no.)5 City or town6 State or province7 Country and ZIP or foreign postal code
8
Enter letter identifying Origin of the Health Coverage (see instructions for codes): ...
9 Reserved
Part II
Information About Certain Employer-Sponsored Coverage (see instructions)
10 Employer name11 Employer identification number (EIN)
12 Street address (including room or suite no.)13 City or town14 State or province15 Country and ZIP or foreign postal code
Part III
Issuer or Other Coverage Provider (see instructions)
16 Name17 Employer identification number (EIN)18 Contact telephone number
19 Street address (including room or suite no.)20 City or town21 State or province22 Country and ZIP or foreign postal code
Part IV
Covered Individuals (Enter the information for each covered individual.)
(a) Name of covered individual(s)(b) SSN or other TIN(c)
DOB (if SSN or other
TIN is not available)
(d)
Covered
all 12 months
(e) Months of coverage
JanFebMarAprMayJunJulAugSepOctNovDec
23
24
25
26
27
28
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 60704B
Form1095-B (2017)
560216
Form 1095-B (2017)
Page 2
Instructions for Recipient
This Form 1095-B provides information needed to report on your income tax
return that you, your spouse (if you file a joint return), and individuals you
claim as dependents had qualifying health coverage (referred to as “minimum
essential coverage”) for some or all months during the year. Individuals who
don't have minimum essential coverage and don't qualify for an exemption
from this requirement may be liable for the individual shared responsibility
payment.
Minimum essential coverage includes government-sponsored programs,
eligible employer-sponsored plans, individual market plans, and other
coverage the Department of Health and Human Services designates as
minimum essential coverage. For more information on the requirement to
have minimum essential coverage and what is minimum essential coverage,
see www.irs.gov/Affordable-Care-Act/Individuals-and-Families/Individual-
Shared-Responsibility-Provision.
TIP
Providers of minimum essential coverage are required to furnish
only one Form 1095-B for all individuals whose coverage is
reported on that form. As the recipient of this Form 1095-B, you
should provide a copy to other individuals covered under the policy if they
request it for their records.
Additional information. For additional information about the tax provisions
of the Affordable Care Act (ACA), including the individual shared
responsibility provisions, the premium tax credit, and the employer shared
responsibility provisions, see www.irs.gov/Affordable-Care-Act/Individuals-
and-Families or call the IRS Healthcare Hotline for ACA questions
(1-800-919-0452).
Part I. Responsible Individual, lines 1–9. Part I reports information about
you and the coverage.
Lines 2 and 3. Line 2 reports your social security number (SSN) or other
taxpayer identification number (TIN), if applicable. For your protection, this
form may show only the last four digits. However, the coverage provider is
required to report your complete SSN or other TIN, if applicable, to the IRS.
Your date of birth will be entered on line 3 only if line 2 is blank.
!
CAUTION
If you don't provide your SSN or other TIN and the SSNs or other TINs
of all covered individuals to the sponsor of the coverage, the IRS may
not be able to match the Form 1095-B with the individuals to
determine that they have complied with the individual shared responsibility
provision.
Line 8. This is the code for the type of coverage in which you or other
covered individuals were enrolled. Only one letter will be entered on this line.
A. Small Business Health Options Program (SHOP)
B. Employer-sponsored coverage
C. Government-sponsored program
D. Individual market insurance
E. Multiemployer plan
F.Other designated minimum essential coverage
TIP
If you or another family member received health insurance
coverage through a Health Insurance Marketplace (also known as
an Exchange), that coverage will generally be reported on a
Form 1095-A rather than a Form 1095-B. If you or another family member
received employer-sponsored coverage, that coverage may be reported on a
Form 1095-C (Part III) rather than a Form 1095-B. For more information, see
www.irs.gov/Affordable-Care-Act/Questions-and-Answers-About-Health-
Care-Information-Forms-for-Individuals.
Line 9. Reserved.
Part II. Information About Certain Employer-Sponsored Coverage, lines
10–15. If you had employer-sponsored health coverage, this part may
provide information about the employer sponsoring the coverage. This part
may show only the last four digits of the employer's EIN. This part also may
be left blank, even if you had employer-sponsored health coverage. If this
part is blank, you do not need to fill in the information or return it to your
employer or other coverage provider.
Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports
information about the coverage provider (insurance company, employer
providing self-insured coverage, government agency sponsoring coverage
under a government program such as Medicaid or Medicare, or other
coverage sponsor). Line 18 reports a telephone number for the coverage
provider that you can call if you have questions about the information
reported on the form.
Part IV. Covered Individuals, lines 23–28. This part reports the name, SSN
or other TIN, and coverage information for each covered individual. A date of
birth will be entered in column (c) only if the SSN or other TIN isn't entered in
column (b). Column (d) will be checked if the individual was covered for at
least one day in every month of the year. For individuals who were covered
for some but not all months, information will be entered in column (e)
indicating the months for which these individuals were covered. If there are
more than six covered individuals, see Part IV, Continuation Sheet(s), for
information about the additional covered individuals.
560317
Form 1095-B (2017)
Page 3
Part IV
Covered Individuals — Continuation Sheet
Name of responsible individualSocial security number (SSN) or other TINDate of birth (if SSN or other TIN is not available)
(a) Name of covered individual(s)(b) SSN or other TIN(c)
DOB (if SSN or other
TIN is not available)
(d)
Covered
all 12 months
(e) Months of coverage
JanFebMarAprMayJunJulAugSepOctNovDec
29
30
31
32
33
34
35
36
37
38
39
40
Form1095-B (2017)
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