LASER MISCELLANEOUS FORMS -...

14 ALL LASERS 50 SHEETS/PACK – WHERE NOTED: BULK PACKAGING 500 SHEETS/PACK

DO NOT STAPLEa Control number For Official Use Only

OMB No. 1545-0008

b Kind of Payer (Check one)

941 Military 943 944

CT-1Hshld. emp.

Medicare govt. emp.

Kind of Employer (Check one)

None apply 501c non-govt.

State/local non-501c State/local 501c Federal govt.

Third-party sick pay

(Check if

applicable)

c Total number of Forms W-2 d Establishment number

e Employer identification number (EIN)

f Employer’s name

g Employer’s address and ZIP code

h Other EIN used this year

1 Wages, tips, other compensation 2 Federal income tax withheld

3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

9 10 Dependent care benefits

11 Nonqualified plans 12a Deferred compensation

12b13 For third-party sick pay use only

14 Income tax withheld by payer of third-party sick pay15 State Employer’s state ID number

16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax

Employer's contact person Employer's telephone number For Official Use Only

Employer's fax number Employer's email address

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.

Signature Title Date

Form Transmittal of Wage and Tax Statements Department of the Treasury Internal Revenue Service

5200LW3 41-0852411

W-3 2015Send this entire page with the entire Copy A page of Form(s) W-2 to the Social Security Administration (SSA). Photocopies are not acceptable. Do not send Form W-3 if you filed electronically with the SSA. Do not send any payment (cash, checks, money orders, etc.) with Forms W-2 and W-3.

ReminderSeparate instructions. See the 2015 General Instructions for Forms W-2 and W-3 for information on completing this form. Do not file Form W-3 for Form(s) W-2 that were submitted electronically to the SSA.

Purpose of FormA Form W-3 Transmittal is completed only when paper Copy A of Form(s) W-2, Wage and Tax Statement, is being filed. Do not file Form W-3 alone. All paper forms must comply with IRS standards and be machine readable. Photocopies are not acceptable. Use a Form W-3 even if only one paper Form W-2 is being filed. Make sure both the Form W-3 and Form(s) W-2 show the correct tax year and Employer Identification Number (EIN). Make a copy of this form and keep it with Copy D (For Employer) of Form(s) W-2 for your records. The IRS recommends retaining copies of these forms for four years.

E-FilingThe SSA strongly suggests employers report Form W-3 and Forms W-2 Copy A electronically instead of on paper. The SSA provides two free e-filing options on its Business Services Online (BSO) website:• W-2 Online. Use fill-in forms to create, save, print, and submit up to 50 Forms W-2 at a time to the SSA.• File Upload. Upload wage files to the SSA you have created using payroll or tax software that formats the files according to the SSA’s Specifications for Filing Forms W-2 Electronically (EFW2).

W-2 Online fill-in forms or file uploads will be on time if submitted by March 31, 2016. For more information, go to www.socialsecurity.gov/employer. First time filers, select “Go to Register”; returning filers select “Go To Log In.”

When To FileMail Form W-3 with Copy A of Form(s) W-2 by February 29, 2016.

Where To File Paper FormsSend this entire page with the entire Copy A page of Form(s) W-2 to:

Social Security Administration Data Operations Center Wilkes-Barre, PA 18769-0001

Note. If you use “Certified Mail” to file, change the ZIP code to “18769-0002.” If you use an IRS-approved private delivery service, add “ATTN: W-2 Process, 1150 E. Mountain Dr.” to the address and change the ZIP code to “18702-7997.” See Publication 15 (Circular E), Employer’s Tax Guide, for a list of IRS-approved private delivery services.

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.

41-0852411L1096 5100

Return this entire page to the Internal Revenue Service. Photocopies are not acceptable.

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.

InstructionsFuture developments. For the latest information about developments related to Form 1096, such as legislation enacted after it was published, go to www.irs.gov/form1096.

Reminder. The only acceptable method of �ling information returns with Internal Revenue Service/Information Returns Branch is electronically through the FIRE system. See Pub. 1220, Speci�cations for Electronic Filing of Forms 1097, 1098, 1099, 3921, 3922, 5498, and W-2G.

Purpose of form. Use this form to transmit paper Forms 1097, 1098, 1099, 3921, 3922, 5498, and W-2G to the Internal Revenue Service. Do not use Form 1096 to transmit electronically. For electronic submissions, see Pub. 1220.

Caution. If you are required to �le 250 or more information returns of any one type, you must �le electronically. If you are required to �le electronically but fail to do so, and you do not have an approved waiver, you may be subject to a penalty. For more information, see part F in the 2015 General Instructions for Certain Information Returns.

Who must file. The name, address, and TIN of the �ler on this form must be the same as those you enter in the upper left area of Forms 1097, 1098, 1099, 3921, 3922, 5498, or W-2G. A �ler is any person or entity who �les any of the forms shown in line 6 above.

Enter the �ler’s name, address (including room, suite, or other unit number), and TIN in the spaces provided on the form.

When to file. File Form 1096 as follows.

• With Forms 1097, 1098, 1099, 3921, 3922, or W-2G, �le by February 29, 2016.

• With Forms 5498, �le by May 31, 2016.

Where To FileSend all information returns �led on paper with Form 1096 to the following.

If your principal business, office or agency, or legal residence in

the case of an individual, is located in

Use the following three-line address

Alabama, Arizona, Arkansas, Connecticut, Delaware, Florida, Georgia, Kentucky, Louisiana, Maine, Massachusetts, Mississippi, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Texas, Vermont, Virginia, West Virginia

Department of the Treasury Internal Revenue Service Center

Austin, TX 73301

For more information and the Privacy Act and Paperwork Reduction Act Notice, see the 2015 General Instructions for Certain Information Returns.

Form 1096 (2015)

Do Not Staple

Form 1096Department of the Treasury Internal Revenue Service

Annual Summary and Transmittal of U.S. Information Returns

OMB No. 1545-0108

2015FILER'S name

Street address (including room or suite number)

City or town, state or province, country, and ZIP or foreign postal code

Name of person to contact Telephone number

Email address Fax number

For Official Use Only

1 Employer identi�cation number 2 Social security number 3 Total number of forms 4 Federal income tax withheld

5 Total amount reported with this Form 1096

6 Enter an “X” in only one box below to indicate the type of form being �led.

W-2G 32

1097-BTC 50

1098 81

1098-C 78

1098-E 84

1098-Q 74

1098-T 83

1099-A 80

1099-B 79

1099-C 85

1099-CAP 73

1099-DIV 91

1099-G 86

1099-INT 92

1099-K 10

1099-LTC 93

1099-MISC 95

1099-OID 96

1099-PATR 97

1099-Q 31

1099-R 98

1099-S 75

1099-SA 94

3921 25

3922 26

5498 28

5498-ESA 72

5498-SA 27

7 If this is your final return, enter an “X” here . . . . .

__ __ __

41-1628061LW2CA

Retirementplan

Third-partysick pay

Statutoryemployee

Employee’s first name and initial

Copy A—For Social Security AdministrationDepartment of the TreasuryInternal Revenue ServiceForm W-2c Corrected Wage and Tax Statement

OMB No. 1545-0008For Official Use Only

Allocated tips7 8

Wages, tips, other compensation Federal income tax withheld

Social security tax withheldSocial security wages 43

Medicare wages and tips

Social security tips

5 Medicare tax withheld

Employer’s name, address, and ZIP codea Tax year/Form correctedc

Employee’s previously reported nameg

Retirementplan

Third-partysick pay

Statutoryemployee

Previously reported Correct information Previously reported Correct information

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

(Rev. 2-2010)

Complete boxes f and/or g only if incorrect on form previously filed

Wages, tips, other compensation

Social security wages3

Allocated tips8

Federal income tax withheld

Social security tax withheld4

Medicare tax withheld

Note: Only complete money fields that are being corrected(exception: for corrections involving MQGE, see the Instructionsfor Forms W-2c and W-3c, boxes 5 and 6).

Employee’s previously reported SSNf

Dependent care benefits9 10Advance EIC payment 9 Advance EIC payment Dependent care benefits10

See instructions for box 1211 12aNonqualified plans 11 Nonqualified plans See instructions for box 1212aCode

12c 12cCode

12b 12bCode

12d 12dCode

State wages, tips, etc.16 16State wages, tips, etc. 16 State wages, tips, etc. State wages, tips, etc.16

State income tax17 17State income tax 17 State income tax State income tax17

Local wages, tips, etc.18 18Local wages, tips, etc. 18 Local wages, tips, etc. Local wages, tips, etc.18

Local income tax19 19Local income tax 19 Local income tax Local income tax19

Locality name20 20Locality name 20 Locality name Locality name20

State 15 State 15 State 15 State

State Correction Information

Locality Correction Information

14 Other (see instructions) 14 Other (see instructions)

Employer’s state ID number Employer’s state ID number Employer’s state ID number Employer’s state ID number

h Last name

Employee’s address and ZIP codei

DO NOT CUT, FOLD, OR STAPLE THIS FORM

Previously reported Correct information Previously reported Correct information

Employer’s Federal EINb

e Corrected SSN and/or name (Check this box and complete boxes f and/org if incorrect on form previously filed.)

Employee’s correct SSNd

••

__ __ __

41-1628061 LW3C

Department of the TreasuryInternal Revenue ServiceTransmittal of Corrected Wage and Tax StatementsW-3cForm

Social Security AdministrationData Operations CenterP.O. Box 3333Wilkes-Barre, PA 18767-3333

Purpose of FormIf you use the U.S. Postal Service, send Forms W-2c and W-3c to thefollowing address:

Where To File

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Use this form to transmit Copy A of Form(s) W-2c, Corrected Wageand Tax Statement (Rev. 2-2009). Make a copy of Form W-3c andkeep it with Copy D (For Employer) of Forms W-2c for your records.File Form W-3c even if only one Form W-2c is being filed or if thoseForms W-2c are being filed only to correct an employee’s name andsocial security number (SSN), or the employer identification number(EIN). See the separate Instructions for Forms W-2c and W-3c forinformation on completing this form.

File this form and Copy A of Form(s) W-2c with the Social SecurityAdministration as soon as possible after you discover an error onForms W-2, W-2AS, W-2GU, W-2CM, W-2VI, or W-2c. Provide CopiesB, C, and 2 of Form W-2c to your employees as soon as possible.

(Rev. 2-2009)

If you use a carrier other than the U.S. Postal Service, send FormsW-2c and W-3c to the following address:

Social Security AdministrationData Operations CenterAttn: W-2c Process1150 E. Mountain DriveWilkes-Barre, PA 18702-7997

When To File

Under penalties of perjury, I declare that I have examined this return, including accompanying documents, and, to the best of my knowledge and belief, it is true,correct, and complete.

DateTitleSignature

Number of Forms W-2c

ed Employer’s Federal EIN

Allocated tips7

Advance EIC payments

Wages, tips, other compensation Federal income tax withheld

Social security tax withheldSocial security wages

12a-d11

Complete boxes h, i, or j only ifincorrect on last form filed.

Employer’s name, address, and ZIP code

Nonqualified plans

Dependent care benefits

(Coded items)

For Official Use OnlyTelephone number

Fax number

OMB No. 1545-0008

16 State wages, tips, etc.

18 Local wages, tips, etc.

State income tax

Local income tax

943Military941/941-SSc

KindofPayer

Medicaregovt. emp.

Hshld.emp.CT-1

Third-partysick pay

h Employer’s incorrect Federal EIN

Total of corrected amounts asshown on enclosed Forms W-2c.

Total of amounts previously reportedas shown on enclosed Forms W-2c.

Total of corrected amounts asshown on enclosed Forms W-2c.

f Establishment number g Employer’s state ID number

i Incorrect establishment number

Contact person

Email address

Explain decreases here:

Has an adjustment been made on an employment tax return filed with the Internal Revenue Service?If “Yes,” give date the return was filed

Yes No

944/944-SS

j Employer’s incorrect state ID number

Advance EIC payments9

Wages, tips, other compensation

Social security wages

Nonqualified plans

16 State wages, tips, etc.

18 Local wages, tips, etc.

Allocated tips8

Federal income tax withheld

Social security tax withheld

Dependent care benefits

(Coded items)

State income tax

Local income tax

14 Inc. tax W/H by 3rd party sick pay payer 14 Inc. tax W/H by 3rd party sick pay payer

DO NOT CUT, FOLD, OR STAPLETax year/Form correcteda

/ W- Give form to therequester. Do notsend to the IRS.

Form W-9 Request for TaxpayerIdenti�cation Number and Certi�cation(Rev. June 2009)

Department of the TreasuryInternal Revenue Service

List account number(s) here (optional)

Address (number, street, and apt. or suite no.)

City, state, and ZIP code

Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. For individuals, this is your social security number (SSN).However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions onpage 3. For other entities, it is your employer identification number (EIN). If you do not have a number,see How to get a TIN on page 3.

Social security number

––or

Requester’s name and address (optional)

Employer identification numberNote: If the account is in more than one name, see the chart on page 4 for guidelines on whose numberto enter. –

Certification

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), andI am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the InternalRevenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS hasnotified me that I am no longer subject to backup withholding, and

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backupwithholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individua l retirementarrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, b ut you mustprovide your correct TIN. (See the instructions on page 4.)

SignHere

Signature ofU.S. person Date

Purpose of Form

Form W-9

Part I

Part II

Business name, if different from above

Check appropriate box:

Under penalties of perjury, I certify that:

U.S. person. Use Form W-9 only if you are a U.S. person(including a resident alien), to provide your correct TIN to theperson requesting it (the requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you arewaiting for a number to be issued),

2. Certify that you are not subject to backup withholding,or

3. Claim exemption from backup withholding if you ar e aU.S. exempt payee.

Foreign person. If you are a foreign person, use theappropriate Form W-8 (see Pub. 515, Withholding of Tax onNonresident Aliens and Foreign Entities).

3. I am a U.S. person (including a U.S. resident alien).

A person who is required to file an information return withthe IRS, must obtain your correct taxpayer identificationnumber (TIN) to report, for example, income paid to you, r ealestate transactions, mortgage inte rest you paid, acquisitionor abandonment of secur ed property, cancellation of debt, orcontributions you made to an IRA.

Individual/Sole proprietor Corporation Partnership Other

Exempt from backupwithholding

Note: If a requester gives you a form other than Form W-9to request your TIN, you should use the requesterís form.However, this for m must meet the acceptable specificationsdescr ibed in Pub. 1167, General Rules and Specifications forSubstitute Tax Forms and Schedules.

Nonresident alien who becomes a resident alien.Generally, only a nonresident alien individual may use theterms of a tax treaty to reduce or eliminate U.S. tax oncertain types of income. However, most tax treaties contain aprovision known as a “saving clause.” Exceptions specifiedin the saving clause may permit an exemption from tax tocontinue for ce rtain types of income even after the recipienthas otherwise become a U.S. resident alien for tax purpose s.

If you are a U.S. resident alien who is relying on anexception contained in the saving clause of a tax tr eaty toclaim an exemption from U.S. tax on certain types of income,you must attach a statement that specifie s the following fiveitems:

1. The treaty country. Generally, this must be the sametreaty under which you claimed exemption fr om tax as anonresident alien.

2. The treaty article addressing the income.3. The article number (or location) in the tax treaty that

contains the saving clause and its exceptions.�. The type and amount of income that qualifie s for the

exemption from tax.5. Sufficient facts to justify the exemption fr om tax under

the terms of the treaty article.

Form 1042-SDepartment of the Treasury Internal Revenue Service

Foreign Person’s U.S. Source Income Subject to Withholding 2015

AMENDED PRO-RATA BASIS REPORTING

OMB No. 1545-0096

Copy A forInternal Revenue Service

1 Income code

2 Gross income 3 Withholding allowances

4 Net income 5 Tax rate.

6 Exemption code

7 Federal tax withheld8 Withholding by other agents9 Total withholding credit

10 Amount repaid to recipient

11 Withholding agent’s EIN EIN QI-EIN

12a WITHHOLDING AGENT’S name

12b Address (number and street)

12c Additional address line (room or suite no.)

12d City or town, province or state, country, ZIP or foreign postal code

13a RECIPIENT’S name 13b Recipient code

13c Address (number and street)

13d Additional address line (room or suite no.)

13e City or town, province or state, country, ZIP or foreign postal code

14 Recipient’s U.S. TIN, if any SSN or ITIN EIN QI-EIN

15 Recipient’s foreign tax identifying number, if any 16 Country code

17 NQI’s/FLOW-THROUGH ENTITY’S name 18 Country code

19a NQI’s/Entity’s address (number and street)

19b Additional address line (room or suite no.)

19c City or town, province or state, country, ZIP or foreign postal code

20 NQI’s/Entity’s U.S. TIN, if any

21 PAYER’S name and TIN (if different from withholding agent’s)

22 Recipient account number (optional)

23 State income tax withheld 24 Payer’s state tax no. 25 Name of state

For Privacy Act and Paperwork Reduction Act Notice, see page 17 of the separate instructions. Form 1042-S (2012)

Form 1042-SDepartment of the Treasury Internal Revenue Service

Foreign Person’s U.S. Source Income Subject to Withholding 2015

AMENDED PRO-RATA BASIS REPORTING

OMB No. 1545-0096

Copy A forInternal Revenue Service

1 Income code

2 Gross income 3 Withholding allowances

4 Net income 5 Tax rate.

6 Exemption code

7 Federal tax withheld8 Withholding by other agents9 Total withholding credit

10 Amount repaid to recipient

11 Withholding agent’s EIN EIN QI-EIN

12a WITHHOLDING AGENT’S name

12b Address (number and street)

12c Additional address line (room or suite no.)

12d City or town, province or state, country, ZIP or foreign postal code

13a RECIPIENT’S name 13b Recipient code

13c Address (number and street)

13d Additional address line (room or suite no.)

13e City or town, province or state, country, ZIP or foreign postal code

14 Recipient’s U.S. TIN, if any SSN or ITIN EIN QI-EIN

15 Recipient’s foreign tax identifying number, if any 16 Country code

17 NQI’s/FLOW-THROUGH ENTITY’S name 18 Country code

19a NQI’s/Entity’s address (number and street)

19b Additional address line (room or suite no.)

19c City or town, province or state, country, ZIP or foreign postal code

20 NQI’s/Entity’s U.S. TIN, if any

21 PAYER’S name and TIN (if different from withholding agent’s)

22 Recipient account number (optional)

23 State income tax withheld 24 Payer’s state tax no. 25 Name of state

For Privacy Act and Paperwork Reduction Act Notice, see page 17 of the separate instructions. L42A 5320 Form 1042-S (2012)

FORM #LW2GA15 LASER W-2 G COPY ALW2GB15 LASER W-2 G COPY BLW2GC215 LASER W-2 G COPY C, 2LW2GD115 LASER W-2 G COPY D, 1

Use EnvelopeDWW2G

Requires 1095BENV EnvelopeRequires 1095CENV Envelope

2015 ACA Software by ComplyRight Item #14035

LASER MISCELLANEOUS FORMS LASER W-3 LASER 1096

LASER 1042S LASER W-2C

LASER W-3C

LASER W-9

FORM # FORM #50’S 500’SLW3 LW3500 LASER W-3 TRANSMITTAL

FORM # FORM #50’S 500’SL1096 L1096500 LASER 1096 TRANSMITTAL

FORM #L42A15 1042S FEDERAL IRS COPY A

L42B15 1042S RECIPIENT COPY BL42C15 1042S RECIPIENT COPY CL42D15 1042S RECIPIENT COPY DL42E15 1042S WITHHOLDING AGENT COPY E

FORM # OPEN DATE HEADINGLW2CA FEDERAL COPY ALW2CB EMPLOYEE COPY BLW2CC EMPLOYEE COPY CLW2C2 EMPLOYEE COPY 2LW2CD1 EMPLOYER / STATE COPY 1/D

FORM #LW3C LASER TRANSMITTAL FOR W-2C

FORM #LW9 LASER FOR W-9

1042S Transmittal available online at IRS.gov

Form 1094-B2014

Transmittal of Health Coverage Information Returns Department of the Treasury Internal Revenue Service

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 identi�cation 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 . . . . . . . . . . . . . .

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.

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 Form 1094-B (2014)

Form 1094-B2014

OMB No. 1545-2252

120115CORRECTED

Form1094-CDepartment of the Treasury Internal Revenue Service

Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns

Information about Form 1094-C and its separate instructions is at www.irs.gov/f1094c.

OMB No. 1545-2251

2014Part I Applicable Large Employer Member (ALE Member)1 Name of ALE Member (Employer) 2 Employer identi�cation 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

9 Name of Designated Government Entity (only if applicable) 10 Employer identi�cation number (EIN)

17 Reserved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18 Total number of Forms 1095-C submitted with this transmittal . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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 �led by and/or on behalf of ALE Member . . . . . . . . . . . . . . . . . . . . . . . . . .

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.

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 Form 1094-C (2014)

“2015 Version Not Released at time of printing”

Form 1094-B2014

OMB No. 1545-2252

Form 1094-B2014

OMB No. 1545-2252

120115CORRECTED

Form1094-CDepartment of the Treasury Internal Revenue Service

Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns

Information about Form 1094-C and its separate instructions is at www.irs.gov/f1094c.

OMB No. 1545-2251

2014Part I Applicable Large Employer Member (ALE Member)1 Name of ALE Member (Employer) 2 Employer identi�cation number (EIN)

9 Name of Designated Government Entity (only if applicable) 10 Employer identi�cation number (EIN)

17 Reserved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18 Total number of Forms 1095-C submitted with this transmittal . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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 �led by and/or on behalf of ALE Member . . . . . . . . . . . . . . . . . . . . . . . . . .

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.

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 Form 1094-C (2014)

FORM #1095B50 ACA - Health Coverage1095C50 Employer-Provided Health

Insurance Offer and Coverage

FORM #1094BT50 Transmittal of Health Coverage

Information Returns1094CT50 Transmittal of Employer-Provided

Health Insurance Offer and Coverage Returns

PRESSURE SEAL FORM #PS1095B500 Form 1095B Health Coverage

14" Pressure Seal EZ FoldPS1095C500 Employer-Provided Health

Insurance Offer and Coverage 14" Pressure Seal EZ Fold

LASER W-2G

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