Form 1094-B Transmittal of Health Coverage Information Returns

Version C Cycle 8

Form

1094-B

Department of the Treasury
Internal Revenue Service
1 Filer's name

3 Name of person to contact

5 Street address (including room or suite no.)

7 State or province

1115

Transmittal of Health Coverage Information Returns
▶ Information

OMB No. 1545-2252

2014

about Form 1094-B and its separate instructions is at www.irs.gov/form1094b.

Internal Use Only
Draft As Of
August 6, 2014

9 Total number of Forms 1095-B submitted with this transmittal .

2 Employer identification number (EIN)

4 Contact telephone number

6 City or town

For Official Use Only

8 Country and ZIP or foreign postal code

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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.

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

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Signature

Title

Cat. No. 61570P

Date
Form

1094-B (2014)