Form 1094-C Form 1094-C Transmittal of Employer-Provided Health Insurance Offer

Version F, Cycle 13

1094-C

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

Form

Department of the Treasury
Internal Revenue Service

Part I

120115

▶ Information

OMB No. 1545-2251

CORRECTED

2014

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

Applicable Large Employer Member (ALE Member)
2 Employer identification number (EIN)

1 Name of ALE Member (Employer)
3 Street address (including room or suite no.)
4 City or town

5 State or province

6 Country and ZIP or foreign postal code

7 Name of person to contact

8 Contact telephone number

9 Name of Designated Government Entity (only if applicable)
11 Street address (including room or suite no.)
12 City or town

Internal Use Only
Draft As Of
October 10, 2014
13 State or province

15 Name of person to contact

17 Reserved .

10 Employer identification number (EIN)

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16 Contact telephone number

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

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19 Is this the authoritative transmittal for this ALE Member? If “Yes,” check the box and continue. If “No,” see instructions

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20 Total number of Forms 1095-C filed by and/or on behalf of ALE Member .

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21 Is ALE Member a member of an Aggregated ALE Group?

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Part II

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For Official Use Only

14 Country and ZIP or foreign postal code

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ALE Member Information

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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.
▲

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▲

Signature

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

Title
Cat. No. 61571A

Date
Form 1094-C (2014)

Version F, Cycle 13

120215
Page 2

Form 1094-C (2014)

Part III

ALE Member Information—Monthly
(a) Minimum Essential Coverage
Offer Indicator
Yes

23

No

(b) Full-Time Employee Count
for ALE Member

(c) Total Employee Count
for ALE Member

(d) Aggregated
Group Indicator

(e) Section 4980H
Transition Relief Indicator

All 12 Months

24

Jan

25

Feb

26

Mar

27

Apr

28

May

29

June

30

July

31

Aug

32

Sept

33

Oct

34

Nov

35

Dec

Internal Use Only
Draft As Of
October 10, 2014

Form 1094-C (2014)

Version F, Cycle 13

120315
Page 3

Form 1094-C (2014)

Part IV

Other ALE Members of Aggregated ALE Group

Enter the names and EINs of Other ALE Members of the Aggregated ALE Group (who were members at any time during the calendar year).

Name

EIN

Name

36

51

37

52

38

53

39

54

40
41
42
43
44
45
46

EIN

Internal Use Only
Draft As Of
October 10, 2014
55
56
57
58
59
60
61

47

62

48

63

49

64

50

65
Form 1094-C (2014)