IRS Forms 1095-C

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FORM 1095-C

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IRS.gov: Affordable Care Act 1095-C, Page 1 IRS.gov: Affordable Care Act 1095-C, Part I  Line 1, Employee's Name IRS.gov: Affordable Care Act 1095-C, Part I  Line 2, Employee's Social Security Number (including dashes) IRS.gov: Affordable Care Act 1095-C, Part I  Lines 3-6, Employee's Complete Address IRS.gov: Affordable Care Act 1095-C, Part I  Line 7, Employer's Name matching information on 1094-C IRS.gov: Affordable Care Act 1095-C, Part I  Line 8, Employer's EIN matching information on 1094-C IRS.gov: Affordable Care Act 1095-C, Part I  Lines 9 and 11-13, Employer's Complete Address matching the information on 1094-C IRS.gov: Affordable Care Act 1095-C, Part I  Line 10, Contact Person's Telephone Number IRS.gov: Affordable Care Act 1095-C, Part II, Employee Offer and Coverage - Plan Start Month IRS.gov: Affordable Care Act 1095-C, Part II  Line 14, Offer of Coverage (Code) IRS.gov: Affordable Care Act 1095-C, Part II  Line 15, Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage IRS.gov: Affordable Care Act 1095-C, Part II  Line 16, Applicable Section 4980H safe Harbor (Code, if applicable) IRS.gov: Affordable Care Act 1095-C, Part III  Lines 17-22, Covered Individuals

Part III: Covered Individuals
Part III Lines 17-22, Covered Individuals




IRS.gov: Affordable Care Act 1095-C, Page 2 IRS.gov: Affordable Care Act 1095-C, Part III  Column (a), Covered Individual's Name IRS.gov: Affordable Care Act 1095-C, Part III  Column (b), Covered Individual's Social Security Number (SSN) IRS.gov: Affordable Care Act 1095-C, Part III  Column (c), Covered Individual's Birthdate (MM/DD/YYY) if Social Security Number (SSN) is not available IRS.gov: Affordable Care Act 1095-C, Part III  Column (d), Covered all 12 months IRS.gov: Affordable Care Act 1095-C, Part III  Column (e), Months of Coverage



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