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IRS Forms 1095-B

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FORM 1095-B

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IRS.gov: Affordable Care Act 1095-B, cLine 1, Name of Responsible Individual IRS.gov: Affordable Care Act 1095-B, Part I Line 2, Social Security Number of Responsible Individual IRS.gov: Affordable Care Act 1095-B, Part I Line 3, Birthdate (MM/DD/YYYY) of Responsible Individual if SSN is blank. IRS.gov: Affordable Care Act 1095-B, Part I Lines 4-7, Complete Mailing Address of the Responsible Individual IRS.gov: Affordable Care Act 1095-B, Part I Line 8, Letter Code of Origin of Policy IRS.gov: Affordable Care Act 1095-B, Part I Line 9, SHOP Identifier (Leave blank for 2015 filing) IRS.gov: Affordable Care Act 1095-B, Part II Lines 10-15, Name, EIN, and Complete Mailing Address for the Employer Sponsoring the Coverage IRS.gov: Affordable Care Act 1095-B, Part III Lines 16-22, Name, EIN, and Complete Mailing Address of Issuer/ Other Coverage IRS.gov: Affordable Care Act 1095-B, Part IV Column (a), Name of each Covered Individual IRS.gov: Affordable Care Act 1095-B, Part IV Column (b), Social Security Number (SSN) of each Covered Individual IRS.gov: Affordable Care Act 1095-B, Part IV Column (c), Birthdate (MM/DD/YYY) of each Covered Individual if SSN is not available IRS.gov: Affordable Care Act 1095-B, Part IV Column (d), Individual Covered for 12 months IRS.gov: Affordable Care Act 1095-B, Part IV Column (e), Coverage each month if individual wasn't covered for all 12 months

Part I: Responsible Individual
Line 1, Name of Responsible Individual
Line 2, Social Security Number of Responsible Individual
Line 3, Birthdate (MM/DD/YYYY) of Responsible Individual if SSN is blank.
Lines 4-7, Complete Mailing Address of the Responsible Individual
Line 8, Letter Code of Origin of Policy (Policy Origin Code)
Line 9, SHOP Identifier (Leave blank for 2015 filing)
Part II: Employer-Sponsored Coverage
Lines 10-15, Name, EIN, and Complete Mailing Address for the Employer Sponsoring the Coverage
Part III: Issuer or Other Coverage Provider
Lines 16-22, Name, EIN, and Complete Mailing Address of Issuer/ Other Coverage
Part IV: Covered Individuals
Column (a), Covered Individual's Name
Column (b), Covered Individual's Social Security Number (SSN)
Column (c), Covered Individual's Birthdate (MM/DD/YYY) if Social Security Number (SSN) is not available
Column (d), Covered all 12 months
Column (e), Months of Coverage




IRS.gov: Affordable Care Act 1095-B, Part IV Column (a), Name of each Covered Individual (Continuation) IRS.gov: Affordable Care Act 1095-B, Part IV Column (b), Social Security Number (SSN) of each Covered Individual (Continuation) IRS.gov: Affordable Care Act 1095-B, Part IV Column (c), Birthdate (MM/DD/YYY) of each Covered Individual if SSN is not available (Continuation) IRS.gov: Affordable Care Act 1095-B, Part IV Column (d), Individual Covered for 12 months (Continuation) IRS.gov: Affordable Care Act 1095-B, Part IV Column (e), Coverage each month if individual wasn't covered for all 12 months (Continuation)

Part IV: Covered Individuals (Continuation)
Column (a), Name of each Covered Individual
Column (b), Social Security Number (SSN) of each Covered Individual
Column (c), Birthdate (MM/DD/YYY) of each Covered Individual if SSN is not available
Column (d), Individual Covered for 12 months
Column (e), Coverage each month if individual wasn't covered for all 12 months



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Related Pages:


IRS Forms 1094-C

Learn more about the IRS Form 1094-C


IRS Forms 1095-C

Learn more about the IRS Form 1095-C


IRS Forms 1094-B

Learn more about the IRS Form 1094-B


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