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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 I: Employee Applicable Large Employer Member (ALE Member/Employer)
Employee
Line 1, Employee's Name
Line 2, Employee's Social Security Number (including dashes)
Lines 3-6, Employee's Complete Address
Employer (Should match information on 1094-C)
Line 7, Employer's Name
Line 8, Employer's EIN
Lines 9 and 11-13, Employer's Complete Address
Line 10, Contact Person's Telephone Number
Part II: Employee Offer and Coverage
Employee Offer and Coverage - Plan Start Month
Line 14, Offer of Coverage (Code)
Line 15, Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage
Line 16, Applicable Section 4980H safe Harbor (Code, if applicable)
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

Part III: 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



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Related Pages:


IRS Forms 1095-B

Learn more about the IRS Form 1095-B


IRS Forms 1094-B

Learn more about the IRS Form 1094-B


IRS Forms 1094-C

Learn more about the IRS Form 1094-C


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