Publication 5223 (Rev. 10-2017) - Internal Revenue … be removed before printing. Part 1 Substitute Statement to Form Recipients Section 1.1 – Purpose The purpose of this publication

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Publication 5223

General Rules and Specifications for Affordable Care Act Substitute Forms 1095-A, 1094-B, 1095-B, 1094-C, and 1095-C

IRSDepartment of the TreasuryInternal Revenue ServicePublication 5223 (Rev. 10-2017)Catalog Number 67909Y

www.irs.gov

of 23 Fileid: ns/P5223/201710/A/XML/Cycle03/source 13:08 - 16-Oct-2017The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

TABLE OF CONTENTS

Part 1 SUBSTITUTE STATEMENT TO FORM RECIPIENTSSection 1.1 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Section 1.2 Electronic Delivery of Recipient Statements . . . . . . . . . . . . . . . . . . . . 2

Part 2 GENERAL INFORMATIONSection 2.1 Which Forms Are Covered? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Section 2.2 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Section 2.3 General Requirements for Acceptable Substitute Forms 1094-B, 1095-

B, 1094-C, and 1095-C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Part 3 SPECIFICATIONS FOR SUBSTITUTE FORMS 1094-B, 1095-B, 1094-C, AND 1095-C (ALL FILED WITH THE IRS)

Section 3.1 Specifications for Forms Filed With the IRS . . . . . . . . . . . . . . . . . . . . 7Section 3.2 Instructions for Preparing Paper Forms That Will Be Filed With the

IRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Part 4 EXHIBITSSection 4.1 Exhibits of Forms in the Publication . . . . . . . . . . . . . . . . . . . . . . . . . 12


Part 1Substitute Statement to Form Recipients

Section 1.1 Purpose

The purpose of this publication is to set forth the tax year 2017 requirements for:

Using official Internal Revenue Service (IRS) forms to file information returns with the IRS,Preparing acceptable substitutes of the official IRS forms to file information returns with the IRS, andUsing official or acceptable substitute forms to furnish information to recipients.

If you do not use the official IRS form to furnish statements to recipients, you must furnish an acceptable substitute statement. Information presented in substitute statements should be in a point size large enough to be easily read by recipients. To be acceptable, your substitute form(s) and recipient statement(s) must comply with the rules in this publication. Generally, information returns may be furnished electronically with the consent of the recipient.

Forms or statements that are furnished to the recipient can be in portrait or landscape format and data fields can be manipulated into any formation as long as they supply the information required by the regulations to the recipient. All data fields must be included on the form. For example, it is not acceptable to furnish a Form 1095-C that does not include Part III. Instructions for the recipient must be included along with the form.

Statements can be furnished to recipients by hand.

This is important tax information and is being furnished to the Internal Revenue Service.

Truncating recipient identification number on recipient statements. Where permitted, filers may truncate the identification number of a recipient or other covered individuals (SSN, ITIN, or ATIN) on the recipient statement (including substitute and composite substitute statements) furnished to the recipient in paper form or electronically. In addition, on Form 1095-B furnished to the recipient, filers may truncate the identification number of the employer reported in Part II (EIN). The filers EIN may not be truncated on the statement. To truncate where allowed, replace the first 5 digits of the 9-digit number with asterisks (*) or Xs (for example, an SSN xxx-xx-xxxx would appear on the paper recipient statement as ***-**-xxxx or XXX-XX-xxxx). See Treasury Decision 9675, 2014-31 I.R.B. 242, available at www.irs.gov/irb/2014-31_IRB/ar07.html.

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Truncation is not allowed on any documents the filer files with the IRS. A filer's identification number may not be truncated on any form.

Section 1.2 Electronic Delivery of Recipient Statements

.If you are required to furnish a written statement to a recipient, then you may furnish the statement electronically instead of on paper. This includes furnishing the statement to recipients of Forms 1095-A, 1095-B, and 1095-C.

If you meet the requirements listed below, you are treated as furnishing the statement timely.

.The recipient must consent in the affirmative and not have withdrawn the consent before the statement is furnished. The consent by the recipient must be made electronically in a way that shows that he or she can access the statement in the electronic format in which it will be furnished. You must notify the recipient of any hardware or software changes prior to furnishing the statement. A new consent to receive the statement electronically is required after the new hardware or software is put into service. Prior to furnishing the statements electronically, you must provide the recipient a statement with the following statements prominently displayed.

If the recipient does not consent to receive the statement electronically, a paper copy will be provided.The scope and duration of the consent. For example, whether the consent applies to every year the statement is furnished or only for the year immediately following the date of the consent.How to obtain a paper copy after giving consent.How to withdraw the consent. The consent may be withdrawn at any time by furnishing the withdrawal in writing (electronically or on paper). Confirmation of the withdrawal also will be in writing (electronically or on paper).Notice of termination. The notice must state under what conditions the statements will no longer be furnished to the recipient.Procedures to update the recipient's information.A description of the hardware and software required to access, print and retain a statement, and a date the statement will no longer be available on the website.

CAUTION!

1.2.1Electronic Recipient Statements

1.2.2Consent

2


.Additionally, you must:

Ensure the electronic format contains all the required information and complies with the guidelines in this document.Ensure the applicable statement is on a website accessible to the recipient through October 15 of that year and is posted on or before the due date.Inform the recipient, electronically or by mail, of the posting and how to access and print the statement.

Part 1 and Part 2, Sections 2.2.4 and 2.3.2 are the only parts of this publication that apply to Form 1095-A.

Part 2General Information

Section 2.1 Which Forms Are Covered?

This publication contains specifications for these information returns:

Form Title1094-B Transmittal of Health Coverage Information Returns 1095-B Health Coverage 1094-C Transmittal of Employer-Provided Health Insurance Offer

and Coverage Information Returns 1095-C Employer-Provided Health Insurance Offer and Coverage

Note. Failure to produce acceptable substitutes of the forms and schedules listed in this publication may result in penalties and delays in processing.

Forms that completely follow the guidelines in this publication and are exact replicas of the official IRS forms do not need to be submitted to the IRS for specific approval. Substitute forms filed with the IRS will be scanned using IRS scanning equipment.

However, software developers and form producers must send a blank copy of their substitute Forms 1094-B, 1095-B, 1094-C, and 1095-C in pdf format to [email protected]. The purpose is not specifically for approval but to assist the IRS in preparing to scan these forms. Submitters will only receive comments if a significant problem is discovered through this process. Submitters are not

CAUTION!

1.2.3Format, Posting, and Notification

3


expected to delay marketing their forms in order to receive feedback. In no case should Submitters include live taxpayer data.

The four or six-digit form ID code in the upper right corner of Forms 1094-B, 1095-B, 1094-C, and 1095-C identifies the official paper form. Generally, the last two digits of the code represent the last year in which major formatting changes were made to the layout of the forms. Developers must have at least 1/4" of white space around the ID code to ensure that it can be properly read by scanning equipment..For purposes of this publication, a substitute form or statement is one that is not published by the IRS. For a substitute form or statement to be acceptable to the IRS, it must conform to the official form or the specifications outlined in this publication. If the substitute form and recipient copy is an exact replica of the IRS form, then you do not need to submit for approval. However, you will still need to forward blank copies to [email protected]. Privately published forms may not state, This is an IRS approved form.

In general, section 6011 of the Internal Revenue Code contains requirements for filers of information returns. A filer must file information returns electronically or on paper. A filer who is required to file 250 or more information returns of any one type during a calendar year must file those returns electronically.

.Further information can be found in Publication 5164, Test Package for Electronic Filers of Affordable Care Act (ACA) Information Returns (AIR), and Publication 5165, Guide for Electronically Filing Affordable Care Act (ACA) Information Returns for Software Developers and Transmitters.

Note. Further information impacting Publication 5223, such as issues arising after its final release, will be posted on IRS.gov at www.irs.gov/pub5223.

Section 2.2 Definitions

.Form recipient means the person to whom you are required by law to furnish a copy of the official form or information statement. The form recipient is referred to as a responsible individual on Form 1095-B and an employee on Form 1095-C.

2.1.1Scope

2.1.2For More Information

2.2.1Form Recipient

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https://www.irs.gov/pub5223


.Filer means the person or organization required by law to file a form listed in Section 2.1 with the IRS.

.Substitute form means a paper substitute of an official form listed in Section 2.1 that totally conforms to the provisions in this publication.

.Substitute form recipient statement means a paper statement of the information reported on Forms 1095-A, 1095-B, and 1095-C. This statement must be furnished to a person (form recipient), as defined under the applicable provisions of the Internal Revenue Code and the applicable regulations.

Section 2.3 General Requirements for Acceptable Substitute Forms 1094-B, 1095-B, 1094-C, and 1095-C

.Paper substitutes for Forms 1094-B, 1095-B, 1094-C, and 1095-C that totally conform to the specifications listed in this publication may be privately printed and filed as returns with the IRS. The reference to the Department of the Treasury Internal Revenue Service should be included on all such forms.

If you are uncertain of any specification and want it clarified, you may submit a letter citing the specification, stating your understanding and interpretation of the specification, and enclosing an example of the form (if appropriate) to:

Internal Revenue ServiceAttn: Substitute Forms ProgramSE:W:CAR:MP:P:TP5000 Ellin Road, C6-440Lanham, MD 20706

Note. Allow at least 30 days for the IRS to respond.

You may also contact the Substitute Forms Program via e-mail at [email protected]. Please enter Substitute Forms on the subject line.

Forms 1094-B, 1095-B, 1094-C, and 1095-C are subject to annual review and possible change. Therefore, filers are cautioned against overstocking supplies of privately printed substitutes.

.

2.2.2Filer

2.2.3Substitute Form

2.2.4Substitute Form Recipient Statement

2.3.1Introduction

2.3.2Logos, Slogans, and Advertisements

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mailto:[email protected]


Logos, slogans, and advertisements are not allowed on copies filed with the IRS.

Some Forms 1095-A, 1094-B, 1095-B, 1094-C, and 1095-C that include logos, slogans, and advertisements may not be recognized as important tax documents. A recipient may not recognize the importance of the recipient copy for tax reporting purposes due to the use of logos, slogans, and advertisements. Thus, the IRS has determined that logos, slogans, and advertising will not be allowed on Forms 1095-A, 1094-B, 1095-B, 1094-C, and 1095-C or any recipient copies, with the following exceptions:

The exact name of the filer or employer, primary trade name, trademark, service mark, or symbol of the filer or employer, an embossment, or watermark on the information return and recipient copies that is a representation of the name, a primary trade name, trademark, service mark, or symbol of the filer or employer;Presented in any typeface, font, stylized fashion, or print color normally used by the filer or employer and used in a non-intrusive manner; andAs long as these items do not materially interfere with the ability of the recipient to recognize, understand, and use the tax information on the recipient copies.

The IRS e-file logo on the IRS official recipient copies may be included, but it is not required, on any of the substitute form copies.

The information return and recipient copies must clearly identify the filer or employer name associated with its employer identification number.

Logos and slogans may be used on permissible enclosures, such as a check or account statement, but cannot be used on information returns and recipient copies.

As indicated, Forms 1095-A, 1094-B, 1095-B, 1094-C, and 1095-C are subject to annual review and possible change. If you have comments about the restrictions on including logos, slogans, and advertising on information returns and recipient copies, send your comments to:

Internal Revenue ServiceAttn: Substitute Forms ProgramSE:W:CAR:MP:P:TP5000 Ellin Road, C6-440Lanham, MD 20706

or email [email protected].

CAUTION!

6



.Proposed substitutes must be exact replicas of the official IRS form with respect to layout and content. Proposed substitutes that do not conform to the specifications in this publication are not acceptable. Further, if you file such forms with the IRS, you may be subject to a penalty for failure to file a correct information return under section 6721 of the Code. The amount of the penalty is based on when you file the correct information return. The penalty is:

$50 per information return if you correctly file within 30 days of the due date of the return; maximum penalty $536,000 per year ($187,500 for small businesses).$100 per information return if you correctly file more than 30 days after the due date but by August 1; maximum penalty $1,609,000 per year ($536,000 for small businesses).$260 per information return if you file after August 1 or you do not file required information returns; maximum penalty $3,218,500 per year ($1,072,500 for small businesses).

There are exceptions for reasonable cause and certain de minimus errors. For more information see Notice 2017-09, 2017-4 I.R.B. 542 at www.irs.gov/irb/2017-04_IRB/ar11.html.

Part 3Specifications for Substitute Forms 1094-B, 1095-B,

1094-C, and 1095-C (All Filed With the IRS)

Section 3.1 Specifications for Forms Filed With the IRS

.Form identifying numbers (for example, 560116 for Form 1095-B) must be printed in nonreflective black carbon-based ink, on each page (including instructions), in print positions 100 through 106, 1 2 inch from the top and right side margin, using an OCR A font. All check boxes on the form must be 10-point boxes with 1/8 inch of white space around each box. Fillable fields must be in Helvetica bold 10-point font. Measurements are generally from the left edge of the paper. Forms must be printed in landscape format and set to print to actual size.

.Color and paper quality for substitute forms as specified by JCP Code 0-25, dated November 29, 1978, must be white 100% bleached chemical wood, optical character recognition (OCR) bond produced in accordance with the following specifications.

2.3.3Penalties

3.1.1General Requirements

3.1.2Color and Paper Quality

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https://www.irs.gov/irb/2017-04_IRB/ar11.htmlhttps://www.irs.gov/irb/2017-04_IRB/ar11.html


Note. Reclaimed fiber in any percentage is permitted provided the requirements of this standard are met.

Acidity: Ph value, average, not less than 4.5Basis Weight: 17 x 22-500 cut sheets 18-20Metric equivalentg/m2 75A tolerance of 5 pct. is allowed.Stiffness: Average, each direction, not less than-milligrams 50Tearing strength: Average, each direction, not less than-grams 40Opacity: Average, not less than-percent 82Thickness: Average-inch 0.0038Metric equivalent-mm 0.097A tolerance of +0.0005 inch (0.0127 mm) is allowed. Paper cannot vary more than 0.0004 inch (0.0102 mm) from one edge to the other.Porosity: Average, not less than-seconds 10Finish (smoothness): Average, each side-seconds 20-55For information only, the Sheffield equivalent-units 170-100Dirt: Average, each side, not to exceed-parts per million 8

.The paper must be:Chemical wood writing paper that is equal to or better than the quality used for the official form,At least 18 pound (17 x 22, 500 sheets), orAt least 50 pound offset book (25 x 38, 500 sheets).

.You must initiate or have a quality control program to assure OCR ink density. Readings will be made when printed on approved 20 lb. white OCR bond with a reflectance of not less than 80%. Black ink must not have a reflectance greater than 15%. These readings are based on requirements of the BancTec IntelliScan XDS Scanner.The following testers and ranges are acceptable:Important information: The forms produced under these specifications must be guaranteed to function properly when processed through High Speed BancTec intelliScan XDS scanners. Forms require precision spacing, printing, and trimming.Density readings on the solid J-6983 must be between the ranges of 0.95 to 0.90. The optimal scanning range is 0.93. Density readings on the solid black must be between the ranges of 112 to 108. The optimal scanning range is 110.

3.1.3Paper Content

3.1.4OCR Specifications

8


Note. The readings are taken using an Ex-Rite 500 series densitometer, in Status T with Obsolute or paper setting under an Illuminate 5000 Kelvin Watt Light. You must maintain print contrast specification of ink and densitometer reflectivity reading throughout entire production run.

MacBeth PCM-II. The tested Print Contrast Signal (PCS) values when using the MacBeth PCM-II tester on the C scale must range from .01 minimum to .06 maximum.Kidder 082A. The tested PCS values when using the Kidder 082A tester on the Infra Red (IR) scale must range from .12 minimum to .21 maximum. White calibration disc must be 100%. Sensitivity must be set at one (1).Alternative testers must be approved by the IRS to establish tested PCS values. You may obtain approval by writing to the following address:

Commissioner of Internal RevenueAttn: SE:W:CAR:MP:P:TPBusiness Publishing Tax Products5000 Ellin RoadLanham, MD 20706

.Type must be substantially identical in size and shape to the official form. The preferred type face is Helvetica; however, the following are acceptable alternatives: Arial, Calibri, and Times New Roman. See Section 3.2.2 for information on the type face used for data entered on the form. All rules are either 1 2-point or 3 4-point.

Note. The form identifying number must be nonreflective carbon-based black ink in OCR A font and printed in the same position.

.Paper substitute Forms 1094-B, 1095-B, 1094-C, and 1095-C that are exact replicas or totally conform to the specifications in this publication do not need a source code. A source code should only be requested if the substitute form will differ from the official IRS form.

Substitute recipient copies that differ from the IRS copy must have a source code affixed to the bottom left corner of the first page of the substitute form as described in Publication 1167, General Rules and Specifications for Substitute Forms and Schedules. You must request a source code from the substitute forms unit by sending an email to [email protected].

.You must include the OMB number in the same location as on the official form.

3.1.5Typography

3.1.6Source Code

3.1.7Required Inclusions/ Exclusions

9



The following Privacy Act and Paperwork Reduction Act Notice phrase must be printed on the forms as follows. It also must be printed on the copy of the form retained by the filer.

For Privacy Act and Paperwork Reduction Act Notice, see the current version of the Instructions for Forms 1094-B, 1095-B, 1094-C, and 1095-C.

A postal indicia may be used if it meets the following criteria:

It is printed in the OCR ink color prescribed for the form, andNo part of the indicia is within one print position of the scannable area.

The printers symbol (GPO) must not be printed on the substitute. Instead, the employer identification number (EIN) of the form's printer must be entered in the bottom margin on the face of each individual form, or on the bottom margin on the back of each form.

Provide a check sheet along with your submission to the substitute forms unit at [email protected]. List the form(s) you are submitting for review and approval. Publication 1167 provides more detail on how submissions should be submitted.

The Catalog Number (Cat. No.) shown on the forms is used for IRS distribution purposes and should not be printed on any substitute forms.

The form must not contain the statement IRS approved or any similar statement.

Section 3.2 Instructions for Preparing Paper Forms That Will Be Filed With the IRS

.The fillable fields for the form recipient's name, street address, city or town, state or province, country and ZIP or foreign postal code, and telephone number (if required) should be typed or machine printed in black ink in the same format as shown on the official IRS form.

The following rules apply to the form recipient's name(s):

The name of the appropriate form recipient must be shown on Part I, line 1.No descriptive information or other name may precede the form recipient's name.Only one form recipient's name may appear on Part I, line 1.

Although handwritten forms will be accepted, the IRS prefers that filers type or machine print data entries. Also, filers should insert data as directed by shading, or in the middle of blocks, well separated from other printing and guidelines, and take measures to guarantee clear, dark black, sharp images.

3.2.1Recipient Information

10



Truncating recipient identification number on recipient statements. Where permitted, filers may truncate the identification number of a recipient or other covered individuals (SSN, ITIN, or ATIN) on the recipient statement (including substitute and composite substitute statements) furnished to the recipient in paper form or electronically. In addition, on Form 1095-B furnished to the recipient, filers may truncate the identification number of the employer reported in Part II (EIN). The filers EIN may not be truncated on the statement. To truncate where allowed, replace the first 5 digits of the 9-digit number with asterisks (*) or Xs (for example, an SSN xxx-xx-xxxx would appear on the paper recipient statement as ***-**-xxxx or XXX-XX-xxxx). See Treasury Decision 9675, 2014-31 I.R.B. 242, available at www.irs.gov/irb/2014-31_IRB/ar07.html.

Truncation is not allowed on any documents the filer files with the IRS. A filer's identification number may not be truncated on any form.

.Machine-printed forms should be printed using a 6 lines/inch option, and should be printed in 10 pitch pica (10 print positions per inch) or 12 pitch elite (12 print positions per inch). Proportional spaced fonts are unacceptable.

Substitute forms prepared in continuous or strip form must be burst and stripped to conform to the size specified for a single sheet before they are filed with the IRS.

Fillable fields must be printed using Helvetica bold 10-point font. If data does not fit using 10 point font, use no less than 8 point font for optimal data recognition. If data will not fit in the space designated for each field, despite making the allowable adjustments, then users can allow information to wrap in a single field. The data for a field must be contained in that specific field and not bleed into adjacent fields.

Do not use a felt tip marker. The machine used to read paper forms generally cannot read this ink type.Do not use dollar signs ($), ampersands (&), asterisks (*), commas (,), or other special characters in the numbered money boxes.Do not use apostrophes (), asterisks (*), or other special characters on the recipient name line.Do not staple forms to the transmitted returns. Any staple holes near the form identifying number may impair the IRSs ability to machine scan the type of documents.

CAUTION!

3.2.2Specifications and Restrictions

11

https://www.irs.gov/irb/2014-31_IRB/ar07.html


.Mail completed paper forms to the IRS service center shown in the Instructions for Forms 1094-B, 1095-B, 1094-C, and 1095-C. Specific information needed to complete the forms mentioned in this publication are given in the specific form instructions.

.The Paperwork Reduction Act (the Act) of 1995 (Public Law 104-13) requires that:

OMB approves all IRS tax forms that are subject to the Act. Each IRS form contains (in or near the upper right corner) the OMB approval number, if any. (The official OMB numbers may be found on the official IRS printed forms and are also shown on the forms in the exhibits in Part 4.)Each IRS form (or its instructions) states:

1. Why the IRS needs the information,

2. How it will be used, and

3. Whether or not the information is required to be furnished to the IRS.

Any substitute form or substitute statement to a recipient must show the OMB number exactly as it appears on the IRS form. This information must be provided to any users of official or substitute IRS forms or instructions.

Part 4Exhibits

Section 4.1 Exhibits of Forms in the Publication

.Exhibits A through H illustrate some of the specifications that were discussed earlier in this publication. The dimensions apply to the actual size forms, but the exhibits have been reduced in size. The dimensions listed on the exhibits apply to all forms in this publication.

.Keep in mind the following guidelines when printing substitute forms.

Closely follow the specifications to avoid delays in processing the forms.

3.2.3Where To File

3.2.4OMB Requirements for All Forms in This Publication

4.1.1Purpose

4.1.2Guidelines

12


Always use the specifications as outlined in this publication and illustrated in the exhibits.

.The following exhibits provide specifications for the forms listed in Section 2.1

Exhibit A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Form 1094-B Exhibit B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Form 1095-B, page 1Exhibit C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Form 1095-B, page 3Exhibit D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Form 1094-C, page 1Exhibit E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Form 1094-C, page 2Exhibit F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Form 1094-C, page 3Exhibit G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Form 1095-C, page 1Exhibit H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Form 1095-C, page 3

4.2Exhibits

13


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ctio

ns

and

th

e la

test

info

rmat

ion

.

OM

B N

o. 1

545-

2252

560116

VO

ID

CO

RR

EC

TED

Par

t I

Res

po

nsi

ble

Ind

ivid

ual

1

Nam

e of

res

pon

sib

le in

div

idua

l2

Soc

ial s

ecur

ity n

umb

er (S

SN

) or

othe

r TI

N3

Dat

e of

birt

h (If

SS

N o

r ot

her

TIN

is n

ot a

vaila

ble

)

4 S

tree

t ad

dre

ss (i

nclu

din

g ap

artm

ent

no.)

5

City

or

tow

n6

S

tate

or

pro

vinc

e7

C

ount

ry a

nd Z

IP o

r fo

reig

n p

osta

l cod

e

9

Res

erve

d

Par

t II

In

form

atio

n a

bo

ut

Cer

tain

Em

plo

yer-

Sp

on

sore

d C

ove

rag

e (s

ee in

stru

ctio

ns)

10

Em

plo

yer

nam

e11

E

mp

loye

r id

enti

catio

n nu

mb

er (E

IN)

12

Str

eet

add

ress

(inc

lud

ing

room

or

suite

no.

)13

C

ity o

r to

wn

14

Sta

te o

r p

rovi

nce

15

Cou

ntry

and

ZIP

or

fore

ign

pos

tal c

ode

Par

t II

I I

ssu

er o

r O

ther

Co

vera

ge

Pro

vid

er (s

ee in

stru

ctio

ns)

16

Nam

e17

E

mp

loye

r id

enti

catio

n nu

mb

er (E

IN)

18

Con

tact

tel

epho

ne n

umb

er

19

Str

eet

add

ress

(inc

lud

ing

room

or

suite

no.

)20

C

ity o

r to

wn

21

Sta

te o

r p

rovi

nce

22

Cou

ntry

and

ZIP

or

fore

ign

pos

tal c

ode

Par

t IV

Co

vere

d In

div

idu

als

(Ent

er t

he in

form

atio

n fo

r ea

ch c

over

ed in

div

idua

l.)

(a) N

ame

of c

over

ed in

div

idua

l(s)

(b) S

SN

or

othe

r TI

N(c

) DO

B (I

f SS

N o

r oth

er

TIN

is n

ot a

vaila

ble)

(d) C

over

ed

all 1

2 m

onth

s(e

) Mon

ths

of c

over

age

Jan

Feb

Mar

Ap

rM

ayJu

nJu

lA

ugS

epO

ctN

ovD

ec

23 24 25 26 27 28 Fo

r P

riva

cy A

ct a

nd

Pap

erw

ork

Red

uct

ion

Act

No

tice

, see

sep

arat

e in

stru

ctio

ns.

Cat

. No.

607

04B

Form

109

5-B

(201

7)

8 E

nter

lett

er id

entif

ying

Orig

in o

f the

Hea

lth C

over

age

(see

inst

ruct

ions

for

cod

es):

..

.

.17

in

.33

in

.50

in

.50

in

.25

in

.50

in

3.5

in

5.40

in

1.9

in2.

1 in

2.5

in

2.50

in1.

20 in

1.0

in

.50

in

.40

in

1.20

in

.33

in

15


Exhibit C Must be in Landscape Form 1095-B Page 3

560317

Form

109

5-B

(201

7)

Pag

e 3

Par

t IV

Co

vere

d In

div

idu

als

C

ontin

uatio

n S

heet

Nam

e of

res

pon

sib

le in

div

idua

lS

ocia

l sec

urity

num

ber

(SS

N) o

r ot

her

TIN

Dat

e of

birt

h (If

SS

N o

r ot

her

TIN

is n

ot a

vaila

ble

)

(a) N

ame

of c

over

ed in

div

idua

l(s)

(b) S

SN

or

othe

r TI

N(c

) DO

B (I

f SS

N o

r oth

er

TIN

is n

ot a

vaila

ble)

(d) C

over

ed

all 1

2 m

onth

s(e

) Mon

ths

of c

over

age

Jan

Feb

Mar

Ap

rM

ayJu

nJu

lA

ugS

epO

ctN

ovD

ec

29 30 31 32 33 34 35 36 37 38 39 40Fo

rm 1

095-

B (2

017)

.25

in

.33

in.5

0 in

.50

in

.50

in

.33

in

16


Exhibit D Must be in Landscape Form 1094-C Page 1

120118

CO

RR

EC

TE

DF

orm10

94-C

Dep

artm

ent

of

the

Tre

asur

y

Inte

rnal

Rev

enue

Ser

vice

Tran

smit

tal o

f Em

ploy

er-P

rovi

ded

Hea

lth

Insu

ranc

e O

ffer

and

Cov

erag

e In

form

atio

n R

etur

ns

Info

rmat

ion

ab

ou

t F

orm

109

4-C

an

d it

s se

par

ate

inst

ruct

ion

s is

at www.irs.gov/form

1094c

OM

B N

o. 1

545-

2251

2017

Par

t I

Ap

plic

able

Lar

ge

Em

plo

yer

Mem

ber

(AL

E M

emb

er)

1 N

ame

of

ALE

Mem

ber

(Em

plo

yer)

2

Em

ploy

er id

enti

catio

n nu

mbe

r (E

IN)

3 S

tree

t ad

dre

ss (i

nclu

din

g r

oo

m o

r su

ite n

o.)

4 C

ity o

r to

wn

5 S

tate

or

pro

vinc

e6

Cou

ntry

and

ZIP

or f

orei

gn p

osta

l cod

e

7 N

ame

of

per

son

to c

ont

act

8 C

ont

act

tele

pho

ne n

umb

er

9 N

ame

of

Des

igna

ted

Go

vern

men

t E

ntity

(onl

y if

app

licab

le)

10 E

mpl

oyer

iden

tica

tion

num

ber (

EIN

)

11 S

tree

t ad

dre

ss (i

nclu

din

g r

oo

m o

r su

ite n

o.)

12 C

ity o

r to

wn

13 S

tate

or

pro

vinc

e14

Cou

ntry

and

ZIP

or f

orei

gn p

osta

l cod

e

15 N

ame

of

per

son

to c

ont

act

16 C

ont

act

tele

pho

ne n

umb

er

Fo

r O

ffici

al U

se O

nly

17 R

eser

ved

..

..

..

..

..

..

..

..

..

..

..

..

..

..

..

..

..

..

..

..

..

..

..

..

..

..

.

18 T

ota

l num

ber

of

Fo

rms

1095

-C s

ubm

itted

with

thi

s tr

ansm

ittal

.

..

..

..

..

..

..

..

..

..

..

..

..

..

..

Par

t II

AL

E M

emb

er In

form

atio

n

19 I

s th

is t

he a

utho

ritat

ive

tran

smitt

al f

or

this

ALE

Mem

ber

? If

Yes

, c

heck

the

bo

x an

d c

ont

inue

. If

No

, s

ee in

stru

ctio

ns

..

..

..

..

..

..

..

..

20 T

ota

l num

ber

of

Fo

rms

1095

-C

led

by

and

/or

on

beh

alf

of

ALE

Mem

ber

..

..

..

..

..

..

..

..

..

..

..

..

..

21 I

s A

LE M

emb

er a

mem

ber

of

an A

gg

reg

ated

ALE

Gro

up?

.

..

..

..

..

..

..

..

..

..

..

..

..

..

..

..

Yes

No

If N

o,

do

no

t co

mp

lete

Par

t IV

.

22 C

erti

fica

tio

ns

of

Elig

ibili

ty (s

elec

t al

l th

at a

pp

ly):

A. Q

ualif

ying

Off

er M

etho

dB

. Res

erve

dC

. Res

erve

dD

. 98%

Off

er M

etho

d

Und

er p

enal

ties

of

per

jury

, I d

ecla

re t

hat

I hav

e ex

amin

ed t

his

retu

rn a

nd a

cco

mp

anyi

ng d

ocu

men

ts, a

nd t

o t

he b

est

of

my

kno

wle

dg

e an

d b

elie

f, t

hey

are

true

, co

rrec

t, a

nd c

om

ple

te.

Sig

natu

re

Titl

e

Dat

e

Fo

r P

riva

cy A

ct a

nd

Pap

erw

ork

Red

uct

ion

Act

No

tice

, see

sep

arat

e in

stru

ctio

ns.

Cat

. No

. 615

71A

Fo

rm 1

094-

C (2

017)

.33

in

.50

in

.50

in

2.16

in

5.8

in1.

70 in

.67

in

.25

in

.50

in

.17

in

1.79

in

.17

in.1

4 in

1.79

in

2.41

in1.

93 in

2.13

in

17


Form 1094-C Page 2Exhibit E Must be in Landscape

120218

Form

109

4-C (2

017)

Pag

e 2

Par

t II

IA

LE

Mem

ber

Info

rmat

ion

M

on

thly

(a) M

inim

um E

ssen

tial C

over

age

O

ffer

Ind

icat

or

Yes

No

(b) S

ectio

n 49

80H

Ful

l-Ti

me

Em

plo

yee

Cou

nt fo

r A

LE M

emb

er(c

) Tot

al E

mp

loye

e C

ount

for

ALE

Mem

ber

(d) A

ggre

gate

d

Gro

up In

dic

ator

(e

) Res

erve

d

23A

ll 12

Mon

ths

24Ja

n

25Fe

b

26M

ar

27A

pr

28M

ay

29Ju

ne

30Ju

ly

31A

ug

32S

ept

33O

ct

34N

ov

35D

ec

Form

109

4-C

(201

7)

.50

in

.50

in

2.2

in

1.1

in

1.9

in1.

5 in

1.1

in

1.9

in

1.4

in

.50

in

.33

in

18


Form 1094-C Page 3Exhibit F Must be in Landscape

120316

Form

109

4-C (2

017)

Page

3P

art I

VO

ther

ALE

Mem

bers

of A

ggre

gate

d A

LE G

roup

Ente

r the

nam

es a

nd E

INs

of O

ther

ALE

Mem

bers

of t

he A

ggre

gate

d AL

E G

roup

(who

wer

e m

embe

rs a

t any

tim

e du

ring

the

cale

ndar

yea

r).

Nam

eEI

N

36 37 38 39 40 41 42 43 44 45 46 47 48 49 50

Nam

eEI

N

51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

Form

109

4-C

(201

7)

3.4

in

1.60

in

.50

in.5

0 in

.33

in

.33

in

19


Form 1095-C Page 1Exhibit G Must be in Landscape

600117

VO

ID

CO

RR

EC

TE

DF

orm

109

5-C

Dep

artm

ent

of

the

Tre

asur

y In

tern

al R

even

ue S

ervi

ce

Em

ploy

er-P

rovi

ded

Hea

lth

Insu

ranc

e O

ffer

and

Cov

erag

e

Do

no

t at

tach

to

yo

ur

tax

retu

rn. K

eep

fo

r yo

ur

reco

rds.

G

o t

o w

ww

.irs.

go

v/F

orm

1095

c fo

r in

stru

ctio

ns

and

th

e la

test

info

rmat

ion

.

OM

B N

o. 1

545-

2251

2017

Par

t I

Em

plo

yee

1 N

ame

of

emp

loye

e 2

So

cial

sec

urity

num

ber

(SS

N)

3 S

tree

t ad

dre

ss (i

nclu

din

g a

par

tmen

t no

.)

4 C

ity o

r to

wn

5 S

tate

or

pro

vinc

e 6

Cou

ntry

and

ZIP

or

fore

ign

post

al c

ode

Ap

plic

able

Lar

ge

Em

plo

yer

Mem

ber

(Em

plo

yer)

7 N

ame

of

emp

loye

r 8

Em

plo

yer

iden

tica

tion

num

ber

(EIN

)

9 S

tree

t ad

dre

ss (i

nclu

din

g r

oo

m o

r su

ite n

o.)

10 C

ont

act

tele

pho

ne n

umb

er

11 C

ity o

r to

wn

12 S

tate

or

pro

vinc

e13

Cou

ntry

and

ZIP

or f

orei

gn p

osta

l cod

e

Par

t II

Em

plo

yee

Off

er o

f C

ove

rag

eP

lan

Sta

rt M

on

th (E

nter

2-d

igit

num

ber

):Al

l 12

Mon

ths

Jan

Feb

Mar

Ap

rM

ayJu

neJu

lyA

ugS

ept

Oct

No

vD

ec14

Off

er o

f C

ove

rag

e (e

nter

re

qui

red

co

de)

15 E

mp

loye

e R

equi

red

C

ont

ribut

ion

(see

in

stru

ctio

ns)

$$

$$

$$

$$

$$

$$

$

16 S

ectio

n 49

80H

S

afe

Har

bo

r an

d

Oth

er R

elie

f (e

nter

co

de,

if a

pp

licab

le)

Par

t II

IC

ove

red

Ind

ivid

ual

s If

Em

plo

yer

pro

vid

ed s

elf-

insu

red

co

vera

ge,

che

ck t

he b

ox

and

ent

er t

he in

form

atio

n fo

r ea

ch in

div

idua

l enr

olle

d in

co

vera

ge,

incl

udin

g t

he e

mp

loye

e.

(a) N

ame

of

cove

red

ind

ivid

ual(s

)(b

) SS

N o

r o

ther

TIN

(c) D

OB

(If

SS

N

o

r o

ther

TIN

is

no

t av

aila

ble

)

(d) C

over

ed

all 1

2 m

onth

s(e

) Mo

nths

of

Co

vera

ge

Jan

Mar

Ap

rM

ayJu

neJu

lyA

ugS

ept

Oct

No

vD

ec

17 18 19

Feb

20 21 22

Fo

r P

riva

cy A

ct a

nd

Pap

erw

ork

Red

uct

ion

Act

No

tice

, see

sep

arat

e in

stru

ctio

ns.

Cat

. No

. 607

05M

Fo

rm 1

095-

C (2

017)

.33

in

1.40

in

.70

in

1.20

in

5 in

3.20

in1.

80 in

1.50

in1.

70 in

.90

in

1 in

.70

in.4

0 in

.33

in

.50

in

.33

in

.33

in.5

0 in

1.00

in

.17

in

.50

in

.33

in

.17

in

20


Form 1095-C Page 3Exhibit H Must be in Landscape

Fo

rm 1

095-

C (2

017)

P

age

3

600317

Nam

e o

f em

plo

yee

So

cial

sec

urity

num

ber

(SS

N)

Par

t II

I C

ove

red

Ind

ivid

ual

s

Co

ntin

uatio

n S

heet

(a) N

ame

of

cove

red

ind

ivid

ual(s

)(b

) SS

N o

r o

ther

TIN

(c) D

OB

(If S

SN

or o

ther

TI

N is

not

ava

ilabl

e)(d

) Cov

ered

al

l 12

mon

ths

(e) M

onth

s of

cov

erag

e

Jan

Feb

Mar

Ap

rM

ayJu

nJu

lA

ugS

ept

Oct

No

vD

ec

23 24 25 26 27 28 29 30 31 32 33 34

Fo

rm 1

095-

C (2

017)

7.60

in2.

40 in

.50

in

.40

in

.33

in

.33

in

21

ContentsPart 1 Substitute Statement to Form RecipientsPurposeElectronic Delivery of Recipient StatementsElectronic Recipient StatementsConsentFormat, Posting, and Notification

Part 2 General InformationWhich Forms Are Covered?Scope For More Information

DefinitionsForm RecipientFilerSubstitute FormSubstitute Form Recipient Statement

General Requirements for Acceptable Substitute Forms 1094-B, 1095-B, 1094-C, and 1095-CIntroductionLogos, Slogans, and AdvertisementsPenalties

Part 3 Specifications for Substitute Forms 1094-B, 1095-B, 1094-C, and 1095-C (All Filed With the IRS)Specifications for Forms Filed With the IRSGeneral RequirementsColor and Paper QualityPaper ContentOCR SpecificationsTypographySource CodeRequired Inclusions/ Exclusions

Instructions for Preparing Paper Forms That Will Be Filed With the IRSRecipient InformationSpecifications and RestrictionsWhere To FileOMB Requirements for All Forms in This Publication

Part 4 ExhibitsExhibits of Forms in the PublicationPurpose Guidelines

Exhibits

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/Description > /Namespace [ (Adobe) (Common) (1.0) ] /OtherNamespaces [ > /FormElements false /GenerateStructure false /IncludeBookmarks false /IncludeHyperlinks false /IncludeInteractive false /IncludeLayers false /IncludeProfiles false /MultimediaHandling /UseObjectSettings /Namespace [ (Adobe) (CreativeSuite) (2.0) ] /PDFXOutputIntentProfileSelector /DocumentCMYK /PreserveEditing true /UntaggedCMYKHandling /LeaveUntagged /UntaggedRGBHandling /UseDocumentProfile /UseDocumentBleed false >> ]>> setdistillerparams> setpagedevice

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Publication 5223 (Rev. 10-2017) - Internal Revenue … be removed before printing. Part 1 Substitute Statement to Form Recipients Section 1.1 – Purpose The purpose of this publication