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Get IRS 1094-C 2020-2021

120118 1094-C Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns Form Department of the Treasury Internal Revenue Service Part I Go OMB No. 1545-2251 CORRECTED to www.irs.gov/Form1094C for instructions and the latest information. 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. Signature For Privacy Act and Paperwork Reduction Act Notice see separate instructions. Title Cat. No. 61571A Date Form 1094-C 2017 Page 2 a Minimum Essential Coverage Offer Indicator b Section 4980H Full-Time Employee Count for ALE Member c Total Employee Count for ALE Member d Aggregated Group Indicator All 12 Months Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 120316 Page 3 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. 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 For Official Use Only 17 Reserved. 18 Total number of Forms 1095-C submitted with this transmittal 19 Is this the authoritative transmittal for this ALE Member If Yes check the box and continue. If No see instructions ALE Member Information 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. Reserved 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. 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 For Official Use Only 17 Reserved. 18 Total number of Forms 1095-C submitted with this transmittal 19 Is this the authoritative transmittal for this ALE Member If Yes check the box and continue. 18 Total number of Forms 1095-C submitted with this transmittal 19 Is this the authoritative transmittal for this ALE Member If Yes check the box and continue. If No see instructions ALE Member Information 21 Is ALE Member a member of an Aggregated ALE Group Yes No If No do not complete Part IV. If No see instructions ALE Member Information 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. Reserved 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. 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 For Official Use Only 17 Reserved. 18 Total number of Forms 1095-C submitted with this transmittal 19 Is this the authoritative transmittal for this ALE Member If Yes check the box and continue. If No see instructions ALE Member Information 21 Is ALE Member a member of an Aggregated ALE Group Yes No If No do not complete Part IV..

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