Form 1095-C

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2014

Department of the Treasury
Internal Revenue Service

Instructions for Forms
1094-C and 1095-C
Section references are to the Internal Revenue Code unless
otherwise noted.

Future Developments

For the latest information about developments related to Form
1094-C, Transmittal of Employer-Provided Health Insurance
Offer and Coverage Information Returns, and Form 1095-C,
Employer-Provided Health Insurance Offer and Coverage, and
instructions, such as legislation enacted after they were
published, go to www.irs.gov/form1094c and www.irs.gov/
form1095c.

Reminders

Forms 1094-C and 1095-C are not required to be filed by any
employer for 2014. However, in preparation for the first required
filing of these forms (that is, filing in 2016 for 2015), employers
may, if they wish, voluntarily file in 2015 for 2014 in accordance
with the forms and these instructions. For more information
about voluntary filing for 2014, visit IRS.gov. No employer
shared responsibility payments under section 4980H will apply
for 2014 for any employer, regardless of whether they voluntarily
file for 2014. For more information on transition relief from the
reporting requirements and employer shared responsibility
payments for 2014, see Notice 2013-45, 2013-31 I.R.B. 116, at
www.irs.gov/irb/2013-31_IRB/ar08.html.

Additional Information

For information related to the Affordable Care Act, visit
www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Home. For
the final regulations under section 6056, Information Reporting
by Applicable Large Employers on Health Insurance Coverage
Offered Under Employer-Sponsored Plans, see T.D. 9661,
2014-13 I.R.B. 855, at www.irs.gov/irb/2014-13_IRB/ar09.html.
For the final regulations under section 6055, Information
Reporting on Minimum Essential Coverage, see T.D. 9660,
2014-13 I.R.B. 842, at www.irs.gov/irb/2014-13_IRB/ar08.html.
For the final regulations under section 4980H, Shared
Responsibility for Employers Regarding Health Coverage, see
T.D. 9655, 2014-9 I.R.B. 541, at www.irs.gov/irb/2014-9_IRB/
ar05.html. For answers to frequently asked questions regarding
the employer shared responsibility provisions and related
information reporting requirements, visit IRS.gov.

General Instructions for Forms
1094-C and 1095-C

See Definitions, later, for key terms used in these instructions.

Purpose of Form

Employers with 50 or more full-time employees (including
full-time equivalent employees) use Forms 1094-C and 1095-C
to report the information required under sections 6055 and 6056
about offers of health coverage and enrollment in health
coverage for their employees. Form 1094-C must be used to
report to the IRS summary information for each employer and to
transmit Forms 1095-C to the IRS. Form 1095-C is used to
report information about each employee. In addition, Forms
1094-C and 1095-C are used in determining whether an
employer owes a payment under the employer shared

Feb 04, 2015

responsibility provisions under section 4980H. Form 1095-C is
also used in determining the eligibility of employees for the
premium tax credit.
Employers that offer employer-sponsored self-insured
coverage also use Form 1095-C to report information to the IRS
and to employees about individuals who have minimum
essential coverage under the employer plan and therefore are
not liable for the individual shared responsibility payment for the
months that they are covered under the plan.

Who Must File

An employer subject to the employer shared responsibility
provisions under section 4980H must file one or more Forms
1094-C (including a Form 1094-C designated as the
Authoritative Transmittal, whether or not filing multiple Forms
1094-C), and must file a Form 1095-C (or a substitute form) for
each employee who was a full-time employee of the employer
for any month of the calendar year. Generally, the employer is
required to furnish a copy of the Form 1095-C to the employee.

TIP

For purposes of reporting on Forms 1094-C and
1095-C, an employee in a Limited Non-Assessment
Period is not considered a full-time employee.

Each employer has its own reporting obligation related to the
health coverage the employer offered (or did not offer) to each of
its full-time employees. An employer subject to the employer
shared responsibility provisions under section 4980H generally
refers to an employer with 50 or more full-time employees
(including full-time equivalent employees) during the prior
calendar year. For more information on which employers are
subject to the employer shared responsibility provisions of
section 4980H, see Employer, later in the Definitions section of
these instructions. For more information on determining full-time
employees, see Full-Time Employee in the Definitions section of
these instructions, which includes information on the treatment
of new hires and employees in Limited Non-Assessment
Periods.
An employer that offers health coverage through an
employer-sponsored self-insured health plan must complete
Form 1095-C, Parts I, II and III, for any employee who enrolls in
the health coverage, whether or not the employee is a full-time
employee for any month of the calendar year.
If the employee who enrolled in self-insured coverage is a
full-time employee for any month of the calendar year, the
employer must also complete Part II. If the employee who
enrolled is not a full-time employee, for any months of the
calendar year (meaning that for all 12 calendar months the
employee was not a full-time employee), the employer must
complete Form 1095-C, Part III and on Part II, must enter code
1G on line 14 in the “All 12 Months” column or in each separate
monthly box (the employer need not complete Part II, lines 15
and 16 in this case).
If an employer is offering health coverage to employees in
another manner, such as through an insured health plan or a
multiemployer health plan, the issuer of the insurance or the
sponsor of the plan providing the coverage is required to furnish
the information about their health coverage to any enrolled

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School District designates the state to report on behalf of the
teachers and reports for itself for its remaining full-time
employees. In this case, either the School District or the state
must file an Authoritative Transmittal reporting aggregate
employer-level data for all full-time employees of the School
District.

employees, and the employer should not complete Form
1095-C, Part III, for those employees.
An employer that offers employer-sponsored self-insured
health coverage but is not an applicable large employer subject
to the employer shared responsibility provisions under section
4980H, should not file Forms 1094-C and 1095-C, but should
instead file Forms 1094-B and 1095-B to report information for
employees who enrolled in the employer-sponsored self-insured
health coverage.

One Form 1095-C for Each Employee of Each
Employer

For each full-time employee of an employer, there must be only
one Form 1095-C filed for employment with that employer. For
example, if an employer separately reports for each of its two
divisions, the employer must combine the offer and coverage
information for any employee who worked at both divisions
during the calendar year so that a single Form 1095-C is filed for
the calendar year for that employee which reports information for
all twelve months of the calendar year from that employer.

Reporting of Enrollment Information for
Non-Employees: Option to Use Forms 1094-B
and 1095-B

Employers that offer employer-sponsored self-insured health
coverage to non-employees who enroll in the coverage may use
Forms 1094-B and 1095-B, rather than Form 1095-C, Part III, to
report coverage for those individuals and other family members.
For information on reporting with respect to non-employees
enrolled in an employer-sponsored self-insured health plan
using Forms 1094-B and 1095-B, see the instructions for those
forms.

In contrast, a full-time employee who works for more than one
employer that is a member of the same Aggregated ALE Group
(that is, works for two separate ALE Members) must receive a
separate Form 1095-C from each employer, unless the ALE
Member is not treated as the employer for any calendar month in
the calendar year as described later. See the Definitions section
of these instructions for a definition of ALE Member.

For employers that use Form 1095-C to report coverage
information for non-employees enrolled in an
employer-sponsored self-insured health plan, such as
non-employee directors, an individual who was a retired
employee during the entire year, or a non-employee COBRA
beneficiary, see the specific instructions for Form 1095-C, Part
III—Covered Individuals (Lines 17-22).

For any calendar month in which a full-time employee works
for more than one ALE Member of an Aggregated ALE Group,
only one ALE Member is treated as the employer and only that
ALE Member reports for that employee for that calendar month
(and the other ALE Member is not required to report for that
employee for that calendar month). If under these rules, an ALE
member is not required to report for an employee for any month
in the calendar year, the employer is not required to report for
that full-time employee for that calendar year. For a description
of the rules related to determining which ALE Member in an
Aggregated ALE Group is treated as the employer for a month in
this situation, see the definition of Employee later.

Authoritative Transmittal for Employers Filing
Multiple Forms 1094-C

A Form 1094-C must be filed when an employer files one or
more Forms 1095-C. An employer may choose to file multiple
Forms 1094-C, accompanied by Forms 1095-C for some of its
employees, provided that a Form 1095-C is filed for each
employee for whom the employer is required to file. In the case
of an Aggregated ALE Group, each separate employer (referred
to in these instructions as an ALE Member or employer) must file
its own Authoritative Transmittal. Although an employer may file
multiple Forms 1094-C, one “Authoritative Transmittal” Form
1094-C, identified on line 19, Part II as the Authoritative
Transmittal, must be filed for each employer reporting aggregate
employer-level data for all full-time employees of the employer.
Specifically, one Authoritative Transmittal must be filed for each
employer, even if multiple Forms 1094-C are filed by and on
behalf of that single employer. For example, if an employer
intends to file a separate Form 1094-C for each of its two
divisions to transmit Forms 1095-C for each division’s full-time
employees, one of the Forms 1094-C filed must be designated
as the Authoritative Transmittal and report aggregate
employer-level data for both divisions, as required in Parts II, III,
and IV of Form 1094-C.

When To File

You will meet the requirement to file Forms 1094-C and 1095-C
if the forms are properly addressed and mailed on or before the
due date. If the regular due date falls on a Saturday, Sunday, or
legal holiday, file by the next business day. A business day is
any day that is not a Saturday, Sunday, or legal holiday.
You must file Forms 1094-C and 1095-C by February 28 if
filing on paper (or March 31 if filing electronically) of the year
following the calendar year to which the return relates. For
calendar year 2014, there is no filing requirement, but employers
may voluntarily file Forms 1094-C and 1095-C.
For calendar year 2015, Forms 1094-C and 1095-C are
required to be filed by February 29, 2016, or March 31, 2016, if
filing electronically.

The same rules apply in the case of a Governmental Unit that
has delegated its reporting responsibilities for some of its
employees to another Governmental Unit—see Designated
Governmental Entity (DGE) in the Definitions section of these
instructions for more information. In the case of a Governmental
Unit that has delegated its reporting responsibilities for some of
its employees, the Governmental Unit must ensure that among
the multiple Forms 1094-C filed by or on behalf of the
Governmental Unit transmitting Forms 1095-C for the
Governmental Unit’s employees, one of the filed Forms 1094-C
is designated as the Authoritative Transmittal and reports
aggregate employer-level data for the Governmental Unit, as
required in Parts II, III, and IV of Form 1094-C.

See the Furnishing Forms 1095-C to Employees section of
these instructions for information on when Form 1095-C must be
furnished.

Where To File

Send all information returns filed on paper to the following:

Example. County is an ALE made up of ALE Members
School District, Police District, and County General Office.
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Instructions for Forms 1094-C and 1095-C (2014)

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If your principal business,
office or agency, or legal
residence in the case of an
individual, is located in:
▼
Alabama, Arizona, Arkansas,
Connecticut, Delaware, Florida,
Georgia, Kentucky, Louisiana,
Maine, Massachusetts,
Mississippi, New Hampshire,
New Jersey, New Mexico, New
York, North Carolina, Ohio,
Pennsylvania, Rhode Island,
Texas, Vermont, Virginia,
West Virginia
Alaska, California, Colorado,
District of Columbia, Hawaii,
Idaho, Illinois, Indiana, Iowa,
Kansas, Maryland, Michigan,
Minnesota, Missouri, Montana,
Nebraska, Nevada, North
Dakota, Oklahoma, Oregon,
South Carolina, South Dakota,
Tennessee, Utah, Washington,
Wisconsin, Wyoming

Use the following address:

An employer must furnish a Form 1095-C to each of its
full-time employees by January 31 of the year following the year
to which the Form 1095-C relates.

▼

The first Forms 1095-C are due to individuals by February 1,
2016.
For more information on alternative furnishing methods for
employers, see the Qualifying Offer Method and the Qualifying
Offer Method Transition Relief for 2015, later.

Department of the Treasury
Internal Revenue Service
Center
Austin, TX 73301

Filers of Form 1095-C may truncate the social security
number (SSN) of an individual (the employee or any family
member of the employee receiving coverage) on Form 1095-C
statements furnished to employees by showing only the last four
digits of the SSN and replacing the first five digits with asterisks
(*) or Xs. Truncation is not allowed on forms filed with the IRS. In
addition, an employer identification number (EIN) may not be
truncated on the forms filed with the IRS.
Statements must be furnished on paper by mail, unless the
recipient affirmatively consents to receive the statement in an
electronic format. If mailed, the statement must be sent to the
employee’s last known permanent address, or if no permanent
address is known, to the employee’s temporary address.

Department of the Treasury
Internal Revenue Service
Center
Kansas City, MO 64999

Consent to furnish statement electronically. An employer is
required to obtain affirmative consent to furnish a statement
electronically. This requirement ensures that statements are
furnished electronically only to individuals who are able to
access them. An individual may consent on paper or
electronically, such as by email. If consent is on paper, the
individual must confirm the consent electronically. A statement
may be furnished electronically by email or by informing the
individual how to access the statement on the employer’s
website.

If your legal residence or principal place of business or
principal office or agency is outside the United States, file with
the Department of the Treasury, Internal Revenue Service
Center, Austin, TX 73301.

How To File Electronically

Specific Instructions for Form 1094-C

Form 1094-C and Form 1095-C
are subject to the requirements
to file returns electronically.
Filers of 250 or more information returns must file the returns
electronically. The 250-or-more requirement applies separately
to each type of return and separately to each type of corrected
return.

Part I—Applicable Large Employer Member
(ALE Member)

Note. Forms 1094-C and 1095-C are not required to be filed by
any employer, and no employer shared responsibility payment
will apply for 2014 for any employer.
Line 1. Enter employer's name.

Pub. 5165, Affordable Care Act (ACA) Information Returns
(AIR) Guide for Software Developers and Transmitters, currently
under development, will outline the communication procedures,
transmission formats, business rules, and validation procedures
for returns filed electronically through the AIR system. To
develop software for use with the AIR system, transmitters and
software developers should use the guidelines provided in Pub.
5165 along with the Extensible Markup Language (XML)
Schemas published on IRS.gov. See Pub. 5165 for more
information.

Line 2. Enter the employer’s EIN. An SSN may not be entered
in lieu of an EIN. Enter the 9-digit EIN including the dash.
If you are filing Form 1094-C, a valid EIN is required at
the time the form is filed. If a valid EIN is not provided,
CAUTION
the Form 1094-C will not be processed. If you do not
have an EIN, you may apply for one online. Go to IRS.gov and
enter “EIN” in the search box. You may also apply by faxing or
mailing Form SS-4, Application for Employer Identification
Number, to the IRS. See the Instructions for Form SS-4 for more
information. See Publication 1635, Employer Identification
Number, for more information.

!

You will receive an electronic acknowledgment once you
complete the transaction. Keep it with your records.

Corrected Forms 1094-C and 1095-C

Lines 3–6. Enter the employer’s complete address (including
room or suite no., if applicable). This address should match the
employer’s address used on the Form 1095-C.

Reserved.

Furnishing Forms 1095-C To Employees

Lines 7 and 8. Enter the name and telephone number of the
person to contact who is responsible for answering any
questions.

You will meet the requirement to furnish Form 1095-C to an
employee if the form is properly addressed and mailed on or
before the due date. If the regular due date falls on a Saturday,
Sunday, or legal holiday, file by the next business day. A
business day is any day that is not a Saturday, Sunday, or legal
holiday.

Instructions for Forms 1094-C and 1095-C (2014)

Note. If you are a Designated Governmental Entity (DGE) filing
on behalf of an employer, complete lines 9–16. If you are not a
DGE filing on behalf of an employer do not complete lines 9–16.
Instead skip to line 18. See Designated Governmental Entity or
DGE in the Definitions section of these instructions.
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See the description of the Offer Methods and Section 4980H
Transition Relief, later.
A. Qualifying Offer Method. Check this box if the employer
is eligible to use and is using the Qualifying Offer Method to
report the information on Form 1095–C for one or more full-time
employees. To be eligible to use the Qualifying Offer Method,
the employer must certify that it made a Qualifying Offer to one
or more of its full-time employees for all months during the year
in which the employee was a full-time employee for whom an
employer shared responsibility payment could apply.
If the employer reports using this method, it must not
complete on Form 1095-C, Part II, line 15, for any month for
which a Qualifying Offer is made. Instead it must enter the
Qualifying Offer code 1A on Form 1095-C, line 14, to indicate
that the employee received a Qualifying Offer for all 12 months
(in which case the employer must not, for any month, report the
dollar amount on line 15). An employer is not required to use the
Qualifying Offer Method, even if it is eligible and instead may
enter on line 14 the applicable offer code and on line 15 the
dollar amount required as an employee contribution for the
lowest-cost employee-only coverage providing minimum value
for that month.

Line 9 If a DGE is filing on behalf of the employer, enter the
name of the DGE.
Line 10. Enter the DGE’s EIN (including the dash). An SSN may
not be entered in lieu of an EIN.
If you are a DGE that is filing Form 1094-C, a valid EIN
is required at the time the return is filed. If a valid EIN is
CAUTION
not provided, the return will not be processed. If the
DGE does not have an EIN when filing Form 1094-C it can get
an EIN by applying online at IRS.gov or by faxing or mailing a
completed Form SS-4, Application for Employer Identification
Number. See Publication 1635, Employer Identification Number,
for more information.

!

Lines 11–14. Enter the DGE’s complete address (including
room or suite no., if applicable).
Lines 15 and 16. Enter the name and telephone number of the
person to contact who is responsible for answering any
questions related to the Form 1094–C.
Line 17. This line is reserved for future use.
Line 18. Enter the total number of Forms 1095-C submitted with
this Form 1094-C transmittal.

If the employer is eligible to use the Qualifying Offer
Method, it may report on Form 1095–C by entering the
Qualifying Offer code 1A on Form 1095–C, line 14, for
any month for which it made a Qualifying Offer to an employee,
even if the employee did not receive a Qualifying Offer for all 12
calendar months. However, if employee receives a Qualifying
Offer for less than all 12 months, the employer must furnish a
copy of Form 1095-C to the employee unless the Qualifying
Offer Method Transition Relief described later applies for 2015.

TIP

Part II—ALE Member Information
Line 19. If this Form 1094-C transmittal is the Authoritative
Transmittal that reports aggregate employer-level data for the
employer, check the box on line 19 and complete the remainder
of Part II and Parts III and IV, to the extent applicable. Otherwise,
complete the signature portion of Form 1094-C and leave the
remainder of the form (lines 20-22 of Part II, and all of Parts III
and IV) blank.
There must be only one Authoritative Transmittal filed for
each employer. If this is the only Form 1094-C being filed for the
employer, this Form 1094-C must report aggregate
employer-level data for the employer and be identified on line 19
as the Authoritative Transmittal. If multiple Forms 1094-C are
being filed for an employer so that Forms 1095-C for all full-time
employees of the employer are not attached to a single Form
1094–C transmittal (because Forms 1095-C for some full-time
employees of the employer are being transmitted separately),
one of the Forms 1094-C must report aggregate employer-level
data for the employer and be identified on line 19 as the
Authoritative Transmittal.

Alternative Method of Furnishing Form 1095–C to
Employees under the Qualifying Offer Method. An employer
that is eligible to use the Qualifying Offer Method meets the
requirement to furnish the Form 1095-C to its full-time
employees who received a Qualifying Offer for all 12 months of
the calendar year, and who did not enroll in coverage that is
self-insured coverage, if it furnishes each of those full-time
employees either a copy of Form 1095-C as filed with the IRS or
a statement containing the following information:
Employer name, address, and EIN.
Contact name and telephone number at which the employee
may receive information about the offer of coverage and the
information on the Form 1095-C filed with the IRS for that
employee.
A statement indicating that, for all 12 months of the calendar
year, the employee and his or her spouse and dependents, if
any, received a Qualifying Offer and therefore are not eligible for
a premium tax credit.
A statement directing the employee to see Pub. 974, Premium
Tax Credit (PTC), for more information on eligibility for the
premium tax credit.
For a full-time employee who received a Qualifying Offer and
enrolled in self-insured coverage, the employer must furnish the
information reporting enrollment in the coverage on Form
1095-C, Part III. The employer may not use the alternative
method of furnishing Form 1095-C under the Qualifying Offer
Method for that employee. The employer may provide the
information to the employee by furnishing a copy of Form
1095-C as filed with the IRS (with or without the statement
described above).
B. 2015 Qualifying Offer Method Transition Relief. Check
this box if the employer is eligible for and is using the Qualifying
Offer Method Transition Relief for the 2015 calendar year to
report information on Form 1095-C for one or more full-time
employees. To be eligible to use the Qualifying Offer Method
Transition Relief the employer must certify that it made a

Note. Lines 20–22 should be completed only on the
Authoritative Transmittal for the employer. For more information,
see Authoritative Transmittal for Employees Filing Multiple
Forms 1094-C, earlier.
Line 20. Enter the total number of Forms 1095-C that will be
filed by and/or on behalf of the employer. This includes all Forms
1095-C that are filed with this transmittal including those filed for
any individuals who enrolled in the employer-sponsored
self-insured plan, and for any Forms 1095-C filed with a separate
transmittal filed by or on behalf of the employer.
Line 21. If during any month of the calendar year the employer
was a member of an Aggregated ALE Group, check “Yes.” If you
check “Yes,” also complete the “Aggregated Group Indicator” in
Part III, column (d), and then complete Part IV to list the other
members of the Aggregated ALE Group. If, for all 12 months of
the calendar year, the employer was not a member of an
Aggregated ALE Group, check “No,” and do not complete Part
III, column (d), or Part IV.
Line 22. If the employer meets the eligibility requirements and is
using one of the Offer Methods and/or one of the forms of
Transition Relief indicated, it must check each applicable box.
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Relief Indicator, to indicate the type of section 4980H transition
relief for which it is eligible.
D. 98% Offer Method. Check this box if the employer is
eligible for and is using the 98% Offer Method. To be eligible to
use the 98% Offer Method, an employer must certify that it
offered, for all months of the calendar year, affordable health
coverage providing minimum value to at least 98% of its
employees for whom it is filing a Form 1095-C employee
statement, and offered minimum essential coverage to those
employees’ dependents. The employer is not required to identify
which of the employees for whom it is filing were full-time
employees, but the employer is still required to file Forms
1095-C on behalf of all of its full-time employees. (For this
purpose, the health coverage is affordable if the employer meets
one of the section 4980H affordability safe harbors.)

Qualifying Offer for one or more months of calendar year 2015 to
at least 95% of its full-time employees. For this purpose, an
employee in a Limited Non-Assessment Period is not included in
the 95% calculation.
If an employer reports using this method, it must not complete
Form 1095-C, Part II, line 15, for any month for which a
Qualifying Offer is made or for which Qualifying Offer Method
Transition Relief applies. An employer that reports using this
method must enter on Form 1095–C, line 14, either the
Qualifying Offer code 1A for any months for which the employee
received a Qualifying Offer, or the Qualifying Offer Method
Transition Relief code 1I for any months for which the employee
did not receive a Qualifying Offer. An employer is not required to
use this method, even if it is eligible and the employer may report
on line 14 the applicable offer code and on line 15 the dollar
amount required as an employee contribution for the lowest-cost
employee-only coverage providing minimum value for that
month. An employer may not, for any month, use code 1A or
code 1I and also report the dollar amount on line 15.
Alternative Method of Furnishing Form 1095–C to
Employees under the Qualifying Offer Method Transition
Relief for 2015. Solely for 2015, for any employee of an
employer eligible for the Qualifying Offer Method Transition
Relief who does not receive a Qualifying Offer for all 12 calendar
months, including employees who receive no offer, the employer
may, in lieu of providing the employee with a copy of Form
1095-C, furnish a statement containing the following information.

Note. If an employer uses this method, it is not required to
complete the “Full-Time Employee Count” in Part III, column (b).

Part III—ALE Member Information—Monthly
(Line 23-35)
Column (a) Minimum Essential Coverage Offer Indicator.
If the employer offered minimum essential coverage to at least
95% of its full-time employees and their dependents for the
entire calendar year, enter “X” in the “Yes” checkbox on line 23
for “All 12 Months” or for each of the 12 calendar months.
If the employer offered minimum essential coverage to at least
95% of its full-time employees and their dependents only for
certain calendar months, enter “X” in the “Yes” checkbox for
each applicable month.
For the months, if any, for which the employer did not offer
minimum essential coverage to at least 95% of its full-time
employees and their dependents, enter “X” in the “No” checkbox
for each applicable month.
If the employer did not offer minimum essential coverage to at
least 95% of its full-time employees and their dependents for any
of the 12 months, enter “X” in the “No” checkbox for “All 12
Months” or for each of the 12 calendar months.
However, an employer that did not offer minimum essential
coverage to at least 95% of its full-time employees and their
dependents but is eligible for certain transition relief described in
the instructions later under Section 4980H Transition Relief for
2015 should enter an “X” in the “Yes ”checkbox for Part III,
line 23, column (a), as applicable. See the instructions later
under Section 4980H Transition Relief for 2015.

Employer name, address, and EIN.
Contact name and telephone number at which the employee
may receive information about the offer of coverage (if any) and
the information on the Form 1095-C filed with the IRS for that
employee.
A statement indicating that the employee and his or her
spouse and dependents, if any, may be eligible for a premium
tax credit for one or more months of 2015.
A statement directing the employee to see Pub. 974 for more
information on eligibility for the premium tax credit.
An employer that is eligible for the Qualifying Offer Method
Transition Relief for any employee who receives a Qualifying
Offer for all 12 months of the calendar year may, in lieu of
furnishing the employee a copy of Form 1095-C, furnish a
statement as described in Alternative Method of Furnishing to
Employees Under the Qualifying Offer Method, earlier.
Whether or not an employee received a Qualifying Offer, for
an employee who enrolled in self-insured coverage the employer
must furnish the information reporting enrollment in the coverage
on Form 1095-C, Part III. The employer may not use the
alternative method of furnishing Form 1095-C under the
Qualifying Offer Method or the Qualifying Offer Method
Transition Relief for that employee. Rather, the employer may
provide the information to the employee by furnishing a copy of
Form 1095-C as filed with the IRS (with or without the statement
described above).
C. Section 4980H Transition Relief. Check this box if the
employer is eligible for section 4980H Transition Relief under
either:
1. 2015 Section 4980H Transition Relief for ALEs with
Fewer Than 100 Full-Time Employees, Including Full-Time
Equivalent Employees (50-99 Transition Relief), or
2. 2015 Transition Relief for Calculation of Assessable
Payments Under Section 4980H(a) for ALEs with 100 or More
Full-Time Employees, Including Full-Time Equivalent Employees
(100 or More Transition Relief) apply.

Note. For purposes of column (a), an employee in a Limited
Non-Assessment Period is not counted in determining whether
minimum essential coverage was offered to at least 95% of an
employer’s full-time employees and their dependents.
An employee who is treated as having been offered
health coverage for purposes of section 4980H (even
though not actually offered) is treated as offered
minimum essential coverage for this purpose. For example, for
the months for which the employer is eligible for dependent
coverage transition relief, non-calendar year transition relief, or
multiemployer arrangement interim guidance (if the employer is
contributing on behalf of an employee but the employee is not
eligible for coverage under the multiemployer plan) with respect
to an employee, that employee should be treated as having
been offered minimum essential coverage for purposes of
column (a). For different rules for purposes of reporting offers of
coverage on Form 1095-C, see the specific instructions for Form
1095-C, Part II, line 14.

TIP

For a description of the relief, including which employers are
eligible for the relief, see Section 4980H Transition Relief for
2015, later. If an employer checks this box, it must also complete
Form 1094-C, Part III, column (e), Section 4980H Transition
Instructions for Forms 1094-C and 1095-C (2014)

TIP
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For purposes of column (a), if the employer offered
minimum essential coverage to all but five of its full-time
employees and their dependents, and five is greater

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highest average monthly number of full-time employees. The
employer must also complete Part III, column (d), to indicate
which months it was part of an Aggregated ALE Group.

than 5% of the number of full-time employees of the employer,
the employer may report in column (a) as if it offered health
coverage to at least 95% of its full-time employees and their
dependents (even if it offered health coverage to less than 95%
of its full-time employees and their dependents, for example to
75 of its 80 full-time employees and their dependents).

If you are filing Form 1094-C, a valid EIN is required at
the time it is filed. If a valid EIN is not provided, the Form
CAUTION
1094-C will not be processed. If you do not have an
EIN, you may apply for one online. Go to IRS.gov and enter
“EIN” in the search box. You may also apply by faxing or mailing
Form SS-4, Application for Employer Identification Number, to
the IRS. See the Instructions for Form SS-4 for more information.
See Publication 1635, Employer Identification Number, for more
information.

!

See Definitions, later, for more information on an Offer of
health coverage.
Column (b) Full-Time Employee Count for ALE Member.
Enter the number of full-time employees for each month, but do
not count any employee in a Limited Non-Assessment Period. (If
the number of full-time employees (excluding employees in a
Limited Non-Assessment Period) for a month is zero, enter 0.)

Specific Instructions for Form 1095-C

Note. If the employer certified that it was eligible for the 98%
Offer Method by selecting box D, on line 22, it is not required to
complete column (b).

Part I—Employee
Line 1. Enter the name of the employee (first name, middle
initial, last name).

Column (c) Total Employee Count for ALE Member. Enter
the total number of employees, including full-time employees
and non-full-time employees and employees in a Limited
Non-Assessment Period, for each calendar month. An employer
must choose to use one of the following days to determine the
number of employees per month and must use the same day for
all months of the year: (1) the first day of each month; (2) the last
day of each month; (3) the first day of the first payroll period that
starts during each month; or (4) the last day of the first payroll
period that starts during each month (provided that for each
month that last day falls within the calendar month in which the
payroll period starts). If the total number of employees was the
same for every month of the entire calendar year, enter that
number in line 23, column (c) “All 12 Months” or in the boxes for
each month of the calendar year. If the number of employees for
any month is zero, enter 0.

Line 2. Enter the 9-digit SSN of the employee including the
dashes.
Lines 3–6. Enter the employee’s complete address (including
apartment no., if applicable). All employers, including U.S.
employers, should enter a country code.

Part I—Applicable Large Employer Member
(Employer)
Line 7. Enter the name of the employer.
Line 8. Enter the employer’s EIN. Do not enter a SSN in lieu of
an EIN. Enter the 9-digit EIN including the dash. The employer’s
name and EIN should match the name and EIN of the employer
reported on lines 1 and 2 of Form 1094-C.

Column (d) Aggregated Group Indicator. An employer must
complete this column if it checked “Yes” on line 21, indicating
that, during any month of the calendar year, it was a member of
an Aggregated ALE Group. If the employer was a member of an
Aggregated ALE Group during each month of the calendar year,
enter “X” in the “All 12 Months” box or in the boxes for each of
the 12 calendar months. If the employer was not a member of an
Aggregated ALE Group for all 12 months but was a member of
an Aggregated ALE Group for one or more month(s), enter “X” in
each month for which it was a member of an Aggregated ALE
Group. If an employer enters “X” in one or more months in this
column, it must also complete Part IV.

If you are filing Form 1095-C, a valid EIN is required at
the time it is filed. If a valid EIN is not provided, the Form
CAUTION
1095-C will not be processed. If you do not have an
EIN, you may apply for one online. Go to IRS.gov and enter
“EIN” in the search box. You may also apply by faxing or mailing
Form SS-4, Application for Employer Identification Number, to
the IRS. See the Instructions for Form SS-4 for more information.
See Publication 1635, Employer Identification Number, for
further information.

!

Lines 9 and 11–13. Enter the employer’s complete address
(including room or suite no., if applicable). This address should
match the address reported on lines 3–6 of the Form 1094-C.

Column (e) Section 4980H Transition Relief Indicator. If the
employer certifies by selecting box C on line 22, that it is eligible
for Section 4980H Transition Relief and is eligible for the 50 to
99 Relief, enter code A. If the employer certifies by selecting box
C on line 22, that it is eligible for Section 4980H Transition Relief
and is eligible for the 100 or More Relief, enter code B. An
employer will not be eligible for both types of relief.

Line 10. Enter the telephone number of the person to contact
whom the recipient may call about the information reported on
the form.

Part II—Employee Offer and Coverage
Line 14. For each calendar month, enter the applicable code
from Code Series 1. If the same code applies for all 12 calendar
months, enter the applicable code in the “All 12 Months” box and
do not complete the individual calendar month boxes, or
complete all of the individual calendar month boxes.
An employer offers health coverage for a month only if it
offers health coverage that would provide coverage for every
day of that calendar month. However, under the employer
shared responsibility provisions under section 4980H, if an
employee terminates employment before the last day of a
calendar month and the health coverage offer ends on the date
of termination, the employer is treated as having offered the
employee health coverage for the month only if the employee

Part IV—Other ALE Members of Aggregated ALE
Group (Lines 36-65)

An employer must complete this section if it checks “Yes” on
line 21. If the employer was a member of an Aggregated ALE
Group for any month of the calendar year, enter the name(s) and
EIN of up to 30 of the other Aggregated ALE Group members. If
there are more than 30 members of the Aggregated ALE Group,
enter the 30 with the highest monthly average number of full-time
employees (using the number reported in Part III, column (b), if a
number was required to be reported) for the year or for the
number of months during which the ALE Member was a member
of the Aggregated ALE Group. Regardless of the number of
members in the Aggregated ALE Group, list only the 30
members in descending order listing first the member with the
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Alternative Furnishing Method for 2015 Qualifying Offer Method
Transition Relief as described in these instructions).

would have been offered health coverage for the entire month
had the employee been employed for the entire month.
A code must be entered for each calendar month January
through December, even if the employee was not a full-time
employee for one or more of the calendar months. Enter the
code identifying the type of health coverage actually offered by
the employer (or on behalf of the employer) to the employee, if
any. Do not enter a code for any other type of health coverage
the employer is treated as having offered (but the employee was
not actually offered). For example, do not enter a code for health
coverage the employer is treated as having offered (but did not
actually offer) under the dependent coverage transition relief,
non-calendar year transition relief, or multiemployer
arrangement interim guidance (if the employer is contributing on
behalf of an employee but the employee is not eligible for
coverage under the multiemployer plan), even if the employee is
included in the count of full-time employees offered minimum
essential coverage for purposes of Form 1094-C, Part III, column
(a).
The information related to whether the full-time employee was
offered coverage (generally meaning the employee was eligible
for coverage under the plan) must be accurate to facilitate
administration of the premium tax credit, including in the case of
coverage offered by a plan such as a multiemployer plan or a
plan sponsored by a staffing firm or similar entity for which the
client employer pays an additional amount for enrolled
employees. The alternative reporting methods may be applied to
the offer of coverage to the extent the employer is otherwise
eligible to use these methods. For example, if a multiemployer
plan represents to a contributing employer that the full-time
employee on behalf of whom the employer contributed was
eligible for coverage that is a Qualifying Offer for all 12 months,
the contributing employer may use the alternative reporting
method related to such a Qualifying Offer. See the sections of
these instructions related to the Qualifying Offer Method,
including the 2015 Qualifying Offer Method Transition Relief.

1B. Minimum essential coverage providing minimum value
offered to employee only.
1C. Minimum essential coverage providing minimum value
offered to employee and at least minimum essential coverage
offered to dependent(s) (not spouse).
1D. Minimum essential coverage providing minimum value
offered to employee and at least minimum essential coverage
offered to spouse (not dependent(s)).
1E. Minimum essential coverage providing minimum value
offered to employee and at least minimum essential coverage
offered to dependent(s) and spouse.
1F. Minimum essential coverage NOT providing minimum
value offered to employee, or employee and spouse or
dependent(s), or employee, spouse and dependents.
1G. Offer of coverage to employee who was not a full-time
employee for any month of the calendar year and who enrolled
in self-insured coverage for one or more months of the calendar
year.
1H. No offer of coverage (employee not offered any health
coverage or employee offered coverage that is not minimum
essential coverage).
1I. Qualifying Offer Transition Relief 2015: Employee (and
spouse or dependents) received no offer of coverage, received
an offer that is not a qualifying offer, or received a qualifying offer
for less than 12 months.
Line 15. Complete line 15 only if code 1B, 1C, 1D, or 1E is
entered on line 14 either in the “All 12 Months” box or in any of
the monthly boxes. Enter the amount of the employee share of
the lowest-cost monthly premium for self-only minimum essential
coverage providing minimum value that is offered to the
employee. Enter the amount including any cents. If the
employee is offered coverage but is not required to contribute
any amount towards the premium, enter “0.00” (do not leave
blank). If the employee share of the lowest-cost monthly
premium amount was the same amount for all 12 calendar
months, enter that monthly amount in each monthly box or enter
that monthly amount in the “All 12 Months” box and do not
complete the monthly boxes. If the employee share of the
lowest-cost monthly amount was not the same for all 12 months,
enter the amount in each calendar month for which the
employee was offered minimum value coverage.

Indicator Codes for Employee Offer and Coverage
(Form 1095-C, Line 14)
Code Series 1, Offer of Coverage. The Code Series 1
indicator codes specify the type of coverage, if any, offered to an
employee, the employee’s spouse, and the employee’s
dependents. The term “dependent” has the specific meaning set
forth in the Definitions section of these instructions. In addition,
for this purpose an offer of coverage is treated as made to an
employee’s dependents only if the offer of coverage is made to
an unlimited number of dependents regardless of the actual
number of dependents, if any, an employee has during any
particular calendar month.
If the type of coverage, if any, offered to an employee was the
same for all 12 months in the calendar year, enter the Code
Series 1 indicator code corresponding to the type of coverage
offered in the “All 12 Months” box or in each of the 12 boxes for
the calendar months.

For line 15, enter the lowest-cost monthly premium for
self-only minimum essential coverage providing
minimum value that is offered to the employee. This
amount may not be the amount the employee is paying for the
coverage, for example, if the employee chose to enroll in more
expensive coverage such as family coverage.

TIP

Line 16. For each calendar month, enter the applicable code, if
any, from Code Series 2. You may enter only one code from
Code Series 2 per calendar month. The instructions below
address which code to use for a month if more than one code
from Series 2 could apply. If the same code applies for all 12
calendar months, enter the applicable code in each monthly box
or enter the code in the “All 12 Months” box. If none of the codes
apply for a calendar month, leave the line blank for that month.

1A. Qualifying Offer: Minimum essential coverage providing
minimum value offered to full-time employee with employee
contribution for self-only coverage equal to or less than 9.5%
mainland single federal poverty line and at least minimum
essential coverage offered to spouse and dependent(s).

Code Series 2—Section 4980H Safe Harbor Codes and
Other Relief for Employers. An employer enters the
applicable Code Series 2 indicator code, if any, on Line 16 to
report for one or more months of the calendar year that one of
the following situations applied to the employee: the employee
was not employed or was not a full-time employee; the
employee enrolled in the minimum essential coverage offered;
the employee was in a Limited Non-Assessment Period with
respect to section 4980H(b); non-calendar year transition relief

This code may be used to report for specific months for
which a Qualifying Offer was made, even if the
employee did not receive a Qualifying Offer for all 12
months of the calendar year. However, an employer may not use
the Alternative Furnishing Method for an employee who did not
receive a Qualifying Offer for all 12 calendar months (except in
cases in which the employer is eligible for and reports using the

TIP

Instructions for Forms 1094-C and 1095-C (2014)

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applied to the employee; the employer met one of the section
4980H affordability safe harbors with respect to this employee,
or the employer was eligible for multiemployer interim rule relief
for this employee. In some circumstances more than one
situation could apply to the same employee in the same month.
For example, an employee could be enrolled in health coverage
for a particular month during which he or she is not a full-time
employee. However, only one code may be used for a particular
calendar month. For any month in which an employee enrolled in
minimum essential coverage, indicator code 2C reporting
enrollment is used instead of any other indicator code that could
also apply. For an employee who did not enroll in health
coverage, there are some specific ordering rules for which code
to use; see the descriptions of the codes.

2H. Section 4980H affordability rate of pay safe harbor. Enter
code 2H if the employer used the section 4980H rate of pay safe
harbor to determine affordability for purposes of section
4980H(b) for this employee for any month(s).
Note. Codes 2F through 2H: Although employers may use the
section 4980H affordability safe harbors to determine
affordability for purposes of the multiemployer interim guidance,
an employer eligible for the relief provided in the multiemployer
interim guidance for a month for an employee should enter code
2E (multiemployer interim rule relief), and not a code for the
section 4980H affordability safe harbors (codes 2F, 2G, or 2H).
2I. Non-calendar year transition relief applies to this
employee. Enter code 2I if non-calendar year transition relief for
section 4980H(b) applies to this employee for the month. See
the instructions later under Section 4980H Transition Relief for
2015 and 2015 Section 4980H(b) Transition Relief for
Employers with Non-Calendar Year Plans (Form 1095-C, line 16,
code 2I), for a description of this relief.

2A. Employee not employed during the month. Enter code 2A
if the employee was not employed on any day of the calendar
month. Do not use code 2A for a month if the individual was an
employee of the employer on any day of the calendar month. Do
not use code 2A for the month during which an employee
terminates employment with the employer.
2B. Employee not a full-time employee. Enter code 2B if the
employee is not a full-time employee for the month and did not
enroll in minimum essential coverage, if offered for the month.
Enter code 2B also if the employee is a full-time employee for
the month and whose offer of coverage (or coverage if the
employee was enrolled) ended before the last day of the month
solely because the employee terminated employment during the
month (so that the offer of coverage or coverage would have
continued if the employee had not terminated employment
during the month). Also use this code for January 2015 if the
employee was offered health coverage no later than the first day
of the first payroll period that begins in January 2015 and the
coverage offered was affordable for purposes of the employer
shared responsibility provisions under section 4980H and
provided minimum value.
2C. Employee enrolled in coverage offered. Enter code 2C for
any month in which the employee enrolled in health coverage
offered by the employer for each day of the month, regardless of
whether any other code in Code Series 2 might also apply (for
example, the code for a section 4980H affordability safe harbor).
2D. Employee in a section 4980H(b) Limited
Non-Assessment Period. Enter code 2D for any month during
which an employee is in a Limited Non-Assessment Period for
section 4980H(b).
If an employee is in an initial measurement period, enter code
2D (employee in a section 4980H(b) Limited Non-Assessment
Period) for the month, and not code 2B (employee not a full-time
employee). For an employee in a section 4980H(b) Limited
Non-Assessment Period for whom the employer is also eligible
for the multiemployer interim rule relief for the month code 2E,
enter code 2E (multiemployer interim rule relief) and not code 2D
(employee in a Limited Non-Assessment Period).
2E. Multiemployer interim rule relief. Enter code 2E for any
month for which the multiemployer interim guidance applies for
that employee. This relief is described under Offer of Health
Coverage in the Definitions section of these instructions.
2F. Section 4980H affordability Form W-2 safe harbor. Enter
code 2F if the employer used the section 4980H Form W-2 safe
harbor to determine affordability for purposes of section
4980H(b) for this employee for the year. If an employer uses this
safe harbor for an employee, it must be used for all months of
the calendar year for which the employee is offered health
coverage.
2G. Section 4980H affordability federal poverty line safe
harbor. Enter code 2G if the employer used the section 4980H
federal poverty line safe harbor to determine affordability for
purposes of section 4980H(b) for this employee for any
month(s).

Part III—Covered Individuals (Lines 17-22)

Complete Part III ONLY if the employer offers
employer-sponsored self-insured health coverage in which the
employee or other individual enrolled. For this purpose,
employer-sponsored self-insured health coverage does not
include coverage under a multiemployer plan.
If the employer is completing Part III, enter “X” in the check
box in Part III. If the employer is not completing Part III, do not
enter “X” in the check box in Part III.
This part must be completed by an employer offering
self-insured health coverage for any individual who was an
employee for one or more calendar months of the year, whether
full-time or non-full-time, and who enrolled in the coverage.
All employee family members that are covered
individuals through the employee’s enrollment (for
example, because the employee elected family
coverage) must be included on the same form as the employee
(or individual to whom the offer was made). For example, if the
employee is offered family coverage by his or her employer
under a self-insured health plan and enrolls in the family
coverage, the employee and the employee’s family members
that are covered under the plan must all be reported on Form
1095-C.

TIP

If two or more employees employed by the same employer
are spouses or employee and dependent, and one employee
enrolled in a coverage option under the plan that also covered
the other employee(s) (for example, one employee spouse
enrolled in family coverage that provided coverage to the other
employee spouse and their employee dependent child), the
enrollment information should be reflected only on the Form
1095-C for the employee who enrolled in the coverage (but
would report the other employee family members as covered
individuals).
Coverage of Non-Employee. This part may be completed by
an employer offering self-insured health coverage for any other
individual who enrolled in the coverage under the plan for one or
more calendar months of the year but was not an employee for
any calendar month of the year, such as a non-employee
director, a retired employee who retired in a previous year, a
terminated employee receiving COBRA coverage who
terminated employment during a previous year, and a
non-employee COBRA beneficiary (but not including an
individual who obtained coverage through the employee’s
enrollment, such as a spouse or dependent obtaining coverage
when an employee elects family coverage). If the Form 1095-C
is used with respect to an individual who was not an employee
for any month of the calendar year, Part II must be completed by
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section 414(b), 414(c), 414(m), or 414(o). An ALE Member is a
member of an Aggregated ALE Group for a month if it is treated
as a single employer with the other members of the group on any
day of the calendar month. If an ALE is made up of only one
person or entity, that one ALE Member is not a part of an
Aggregated ALE Group. Government entities and churches or
conventions or associations of churches may apply a
reasonable, good faith interpretation of the aggregation rules
under section 414 in determining their status as an ALE or
member of an Aggregated ALE Group.

using Code 1G in the “All 12 Months” box or the box for each
month of the calendar year.
In the case of a non-employee individual who enrolls in
the coverage under a self-insured health plan, all family
members that are covered individuals due to the
individual’s enrollment must be included on the same Form
1095-B or Form 1095-C as the individual who is offered, and
enrolls in, the coverage.

TIP

Columns (a) through (d), as applicable, must be completed
for each individual enrolled in the coverage, including the
employee reported on line 1. A date of birth will be entered in
column (c) only if a SSN is not entered in column (b). Column (d)
will be checked if the individual was covered for at least one day
in every month of the year. For individuals who were covered for
some but not all months, information will be entered in column
(e) indicating the months for which these individuals were
covered. If there are more than 6 covered individuals, complete
one or more additional Forms 1095-C, Part I and Part III (do not
complete Part II on the additional Forms 1095-C) and do not
include the additional Forms 1095-C in the count of forms
submitted with the accompanying Form 1094-C.

Applicable Large Employer (ALE). An ALE is, for a particular
calendar year, any single employer, or group of employers
treated as an Aggregated ALE Group, that employed an average
of at least 50 full-time employees (including full-time equivalent
employees) on business days during the preceding calendar
year. A new employer (that is, an employer that was not in
existence on any business day in the prior calendar year) is an
ALE for the current calendar year if it reasonably expects to
employ, and actually does employ, an average of at least 50
full-time employees (including full-time equivalent employees)
on business days during the current calendar year.
Applicable Large Employer Member (ALE Member). An
ALE Member is a single person or entity that is an ALE, or if
applicable, each person or entity that is a member of an
Aggregated ALE Group. A person or entity that does not have
employees or only has employees with no hours of service (for
example, only employees whose entire service consists of work
outside of the United States that does not count as hours of
service under section 4980H) is not an ALE Member.

Governmental Unit employers offering self-insured
TIP health coverage that have delegated another
governmental unit (a DGE) for purposes of reporting
and furnishing enrollment information (meaning the information
that otherwise would be reported on Form 1095-C, Part III), but
have not designated a DGE for purposes of reporting and
furnishing offer of coverage information (meaning the information
that is reported on Form 1095-C, Part II), should file and furnish
Forms 1095-C with a completed Part I and Part II, but not a
completed Part III, and should not check the box indicating
that the Governmental Unit offers self-insured health
coverage. In this case, the DGE should file Forms 1094-B and
1095-B to report enrollment information for employees on behalf
of the Governmental Unit. See FAQs on IRS.gov.

Bona fide volunteer. A bona fide volunteer is an employee of
a government entity or tax-exempt organization whose only
compensation from that entity or organization is (1)
reimbursement for (or reasonable allowance for) reasonable
expenses incurred in the performance of services by volunteers,
or (2) reasonable benefits (including length of service awards),
and nominal fees, customarily paid by similar entities in
connection with the performance of services by volunteers.

A DGE that has been delegated by a Governmental Unit for
purposes of reporting and furnishing both offer of coverage and
enrollment information (meaning the information that would be
reported on Parts II and III of Form 1095-C) should file Forms
1094-C and 1095-C to report the information for employees on
behalf of the Governmental Unit.

Dependent. A dependent is an employee’s child, including a
child who has been legally adopted or legally placed for adoption
with the employee, who has not reached age 26. A child reaches
age 26 on the 26th anniversary of the date the child was born
and is treated as a dependent for the entire calendar month
during which he or she reaches age 26. For this purpose, a
dependent does not include stepchildren, foster children, or a
child that does not reside in the United States (or a country
contiguous to the United States) and who is not a United States
citizen or national. For this purpose, a dependent does not
include a spouse.

Column (a). Enter the name of each covered individual.
Column (b). Enter the 9-digit SSN for each covered individual
including the dashes. For covered individuals who are not the
employee listed in Part I, a Taxpayer Identification Number
(TIN), rather than an SSN, may be entered if the covered
individual does not have an SSN.

Designated Government Entity (DGE). A DGE is a person or
persons that are part of or related to the Governmental Unit that
is the ALE Member and that is appropriately designated for
purposes of these reporting requirements. In the case of a
Governmental Unit that has delegated some or all of its reporting
responsibilities to a DGE with respect to some or all of its
employees, one Authoritative Transmittal must still be filed for
that Governmental Unit reporting aggregate employer-level data
for all employees of the Governmental Unit (including those for
whom the Governmental Unit has delegated its reporting
responsibilities). For more information, see the section entitled
Authoritative Transmittal for Employers Filing Multiple Forms
1094-C.

Column (c). Enter a date of birth (MM/DD/YYYY) for the
covered individual only if column (b) is blank.
Column (d). Check this box if the individual was covered for at
least one day per month for all 12 months of the calendar year.
Column (e). If the individual was not covered for all 12 months
of the calendar year, check the applicable box(es) for the
months in which the individual was covered for at least one day
in the month.

Definitions

This section contains the definitions of key terms used in Forms
1094-C and 1095-C and these instructions. For definitions of
terms not included in this section, see the final regulations under
section 4980H, T.D. 9655, 2014-9 I.R.B. and section 6056, T.D.
9661, 2014-13 I.R.B.

Eligible Employer-Sponsored Plan. An eligible
Employer-Sponsored Plan refers to group health insurance
coverage for employees under (1) a governmental plan, such as
the Federal Employees Health Benefits Program (FEHB), (2) an
insured plan or coverage offered in the small or large group
market within a state, (3) a grandfathered health plan offered in a

Aggregated ALE Group. An Aggregated ALE Group refers to
a group of ALE Members treated as a single employer under
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are counted as the equivalent of a full-time employee solely for
purposes of determining whether the employer is an ALE. For
rules on how to determine full-time equivalent employees, see
Regulations section 54.4980H-2(c).

group market, or (4) a self-insured group health plan for
employees.
Employee. For this purpose, an employee is an individual who
is an employee under the common-law standard for determining
employer-employee relationships. An employee does not
include a sole proprietor, a partner in a partnership, a S
corporation shareholder who owns at least 2-percent of the S
corporation, a leased employee within the meaning of section
414(n) of the Code, or a worker that is a qualified real estate
agent or direct seller. If an employee is an employee of more
than one employer of the same Aggregated ALE Group during a
calendar month, the employee is treated as an employee of the
employer for whom the employee has the greatest number of
hours of service for that calendar month; if the employee has an
equal number of hours of service for two or more employers of
the same Aggregated ALE Group for the calendar month, those
employers must treat one of the employers as the employer of
that employee for that calendar month. See the section entitled
“One Form 1095-C for Each Employee of Each Employer” for a
discussion of reporting in these circumstances. See Publication
15-A, Employer’s Supplemental Tax Guide, for more information
on determining who is an employee.

Governmental Unit and Agency or Instrumentality of a
Governmental Unit. A Governmental Unit is the government of
the United States, any State or political subdivision thereof, or
any Indian tribal government (as defined in section 7701(a)(40))
or subdivision of an Indian tribal government (as defined in
section 7871(d)). For purposes of these instructions, references
to a Governmental Unit include an Agency or Instrumentality of a
Governmental Unit. Until guidance is issued that defines the
term Agency or Instrumentality of a Governmental Unit for
purposes of section 6056, an entity may determine whether it is
an Agency or Instrumentality of a Governmental Unit based on a
reasonable and good faith interpretation of existing rules relating
to agency or instrumentality determinations for other federal tax
purposes.
Health coverage. As used in these instructions, refers to
minimum essential coverage, unless otherwise indicated.
Hours of service. An hour of service is each hour for which an
employee is paid, or entitled to payment, for the performance of
duties for the employer, and each hour for which an employee is
paid, or entitled to payment, for a period of time during which no
duties are performed due to vacation, holiday, illness, incapacity
(including disability), layoff, jury duty, military duty, or leave of
absence. An hour of service does not include any hour of service
performed as a Bona Fide Volunteer of a government entity or
tax-exempt entity, as part of a Federal Work-Study Program (or
a substantially similar program of a State or political subdivision
thereof) or to the extent the compensation for services
performed constitutes income from sources without the United
States. See www.irs.gov/irb/2014-13_IRB/ar09.html for a
discussion of determination of hours of service for categories of
employees for whom the general rules for determining hours of
service may present special difficulties (including adjunct faculty
and commissioned salespeople) and certain categories of work
hours associated with some positions of employment, including
layover hours (for example, for certain airline employees),
on-call hours, and work performed by an individual who is
subject to a vow of poverty as a member of a religious order.

Employer. For purposes of these instructions, an employer is
the person that is the employer of an employee under the
common-law standard for determining employer-employee
relationships and that is subject to the employer shared
responsibility provisions of section 4980H (these employers are
referred to as ALE Members). For more information on which
employers are ALE Members, see the definition of Applicable
Large Employer Member (ALE Member).
Full-time employee. A full-time employee is an employee who,
for a calendar month, is employed an average of at least 30
hours of service per week with the employer. For this purpose,
130 service hours in a calendar month is treated as the monthly
equivalent of at least 30 hours per week. An employer must
complete information for all twelve months of the calendar year
for any of its employees who were full-time employees for one or
more months of the calendar year. For more information on the
identification of full-time employees, see Regulations sections
54.4980H-1(a)(21) and 54.4980H-3 and Notice 2014-49,
2014-41 I.R.B 66 (which describes a proposed approach to the
application of the look-back measurement method in situations
in which the measurement period applicable to an employee
changes).

Limited Non-Assessment Period. A Limited Non-Assessment
Period generally refers to a period during which an ALE Member
will not be subject to an assessable payment under section
4980H(a), and in certain cases section 4980H(b), for a full-time
employee, regardless of whether that employee is offered health
coverage during that period.
The first five periods described below are Limited
Non-Assessment Periods only if the employee is offered health
coverage by the first day of the first month following the end of
the period, and are Limited Non-Assessment Periods for section
4980H(b) only if the health coverage that is offered at the end of
the period provides minimum value. For more information on
Limited Non-Assessment Periods and the application of section
4980H, see Regulations section 54.4980H-1(a)(26).
First Year as ALE Period. January through March of the first
calendar year in which an employer is an ALE, but only for an
employee who was not offered health coverage by the employer
at any point during the prior calendar year. For this purpose,
2015 is not the first year an employer is an ALE, if that employer
was an ALE in 2014 (notwithstanding that transition relief
provides that no employer shared responsibility payments under
section 4980H will apply for 2014 for any employer).
Waiting Period under the Monthly Measurement Method. If an
employer is using the monthly measurement method to
determine whether an employee is a full-time employee, the
period beginning with the first full calendar month in which the

Note. A retiree (meaning an individual who was not an
employee during the applicable period) is not a full-time
employee. However, if the retiree was a full-time employee for
any month of the calendar year (for example, before retiring
mid-year), the employer must complete information in Part II of
Form 1095-C for all twelve months of the calendar year, using
the appropriate codes.
An employer need not file a Form 1095-C for an
individual who for each month of a calendar year is
either not an employee of the employer or is an
employee in a limited non-assessment period. However, for the
months in which the employee was an employee of the
employer, such an employee would be included in the total
employee count reported on Form 1094-C, Part III, Column (c).
Also, if during the Limited Non-Assessment Period the employee
enrolled in coverage under a self-insured employer-sponsored
plan, the employer must file a Form 1095-C for the employee to
report coverage information for the year.

TIP

Full-time equivalent employee. A combination of employees,
each of whom individually is not treated as a full-time employee
because he or she is not employed on average at least 30 hours
of service per week with an employer, but who, in combination,
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For purposes of reporting, an offer to a spouse includes an
offer to a spouse that is subject to a reasonable, objective
condition, regardless of whether the spouse meets the
reasonable, objective condition. For example, an offer of
coverage that is available to a spouse only if the spouse certifies
that the spouse does not have access to health coverage from
another employer is treated as an offer of coverage to the
spouse for reporting purposes. Note that this treatment is for
reporting purposes only, and generally will not affect the
spouse’s eligibility for the premium tax credit if the spouse did
not meet the condition and therefore did not have an actual offer
of coverage.
An employer offers health coverage for a month only if it
offers health coverage that would provide coverage for every
day of that calendar month. For reporting purposes, this means
that an offer of coverage does not occur for a month if an
employee’s employment terminates before the last day of a
calendar month and the health coverage also ends before the
last day of that calendar month (or for an employee who didn’t
enroll in coverage, the coverage would have ended if the
employee had enrolled in coverage). However, see the
description of Code Series 2—Section 4980H Safe Harbor
Codes and Other Relief for Employers, code 2B which may be
applicable in these circumstances to indicate that the employer
is treated as having offered coverage for the entire month for
purposes of section 4980H.
An employer offers health coverage to an employee if it, or
another employer in the Aggregated ALE Group, or a third party
such as a multiemployer or single employer Taft-Hartley plan, a
multiple employer welfare arrangement (MEWA), or, in certain
cases, a staffing firm, offers health coverage on behalf of the
employer.

employee is first otherwise (but for completion of the waiting
period) eligible for an offer of health coverage and ending no
later than two full calendar months after the end of that first
calendar month.
Waiting Period under the Look-Back Measurement Method. If
an employer is using the look-back measurement method to
determine whether an employee is a full-time employee and the
employee is reasonably expected to be a full-time employee at
his or her start date, the period beginning on the employee’s
start date and ending not later than the end of the employee’s
third full calendar month of employment.
Initial Measurement Period and Associated Administrative
Period under the Look-Back Measurement Method. If an
employer is using the look-back measurement method to
determine whether a new employee is a full-time employee, and
the employee is a variable hour employee, seasonal employee
or part-time employee, the initial measurement period for that
employee and the administrative period immediately following
the end of that initial measurement period.
Period Following Change in Status that Occurs During Initial
Measurement Period Under the Look-Back Measurement
Method. If an employer is using the look-back measurement
method to determine whether a new employee is a full-time
employee, and, as of the employee’s start date, the employee is
a variable hour employee, seasonal employee or part-time
employee, but, during the initial measurement period, the
employee has a change in employment status such that, if the
employee had begun employment in the new position or status,
the employee would have reasonably been expected to be a
full-time employee, the period beginning on the date of the
employee’s change in employment status and ending not later
than the end of the third full calendar month following the change
in employment status. If the employee is a full-time employee
based on the initial measurement period and the associated
stability period starts sooner than the end of the third full
calendar month following the change in employment status, this
Limited Non-Assessment Period ends on the day before the first
day of that associated stability period.
First Calendar Month of Employment. If the employee’s first
day of employment is a day other than the first day of the
calendar month, then the employee’s first calendar month of
employment is a Limited Non-Assessment Period.

Interim Guidance Regarding Multiemployer
Arrangements. An employer is treated as offering health
coverage to an employee if the employer is required by
a collective bargaining agreement or related participation
agreement to make contributions for that employee to a
multiemployer plan that offers, to individuals who satisfy the
plan’s eligibility conditions, health coverage that is affordable
and provides minimum value, and that also offers health
coverage to those individuals’ dependents or is eligible for the
section 4980H transition relief regarding offers of coverage to
dependents. For more information, see section XV.E of the
preamble to the final section 4980H regulations.

TIP

Minimum essential coverage (MEC). Although various types
of health coverage may qualify as minimum essential coverage,
for purposes of these instructions, minimum essential coverage
refers to health coverage under an eligible employer-sponsored
plan. For more details on Minimum essential coverage, see
Minimum essential coverage in Pub. 974.

Qualifying offer. A qualifying offer is an offer of MEC providing
minimum value to one or more full-time employees for all
calendar months during the calendar year for which the
employee was a full-time employee for whom a section 4980H
assessable payment could apply, at an employee cost for
employee-only coverage for each month not exceeding 9.5
percent of the mainland single federal poverty line divided by 12,
provided that the offer includes an offer of MEC to the
employee’s spouse and dependents (if any).

Minimum value. A plan provides minimum value if the plan
pays at least 60 percent of the costs of benefits for a standard
population.
Offer of health coverage. An employer makes an offer of
coverage to an employee if it provides the employee an effective
opportunity to enroll in the health coverage (or to decline that
coverage) at least once for each plan year. An employer makes
an offer of health coverage to an employee for the plan year if it
continues the employee’s election of coverage from a prior year
but provides the employee an effective opportunity to opt out of
the health coverage. If an employer provides health coverage to
an employee but does not provide the employee an effective
opportunity to decline the coverage, the employer is treated as
having made an offer of health coverage to the employee only if
that health coverage provides minimum value and does not
require an employee contribution for the coverage for any
calendar month of more than 9.5 percent of a monthly amount
determined as the mainland federal poverty line for a single
individual for the applicable calendar year, divided by 12.
Instructions for Forms 1094-C and 1095-C (2014)

Section 4980H Transition Relief for 2015

This section describes various types of section 4980H transition
relief and how an employer reports its eligibility for any particular
type of relief. For more details regarding this, and other, section
4980H transition relief, see section XV of the preamble to the
final regulations under section 4980H.
The transition relief described in this section is solely for the
employer for purposes of section 4980H and does not affect the
employee’s potential eligibility for the premium tax credit.
Accordingly, regardless of whether the employer is eligible for
relief under section 4980H for an employee for one or more
months, the Form 1095-C for that employee must accurately
report the health coverage offered to that employee (if any)
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have had an average of 100 full-time employees (including
full-time equivalent employees) on business days in 2014.
However, as a result of the terminations, it had an average of
only 97 full-time employees (including full-time equivalent
employees) for business days in 2014. During the period of
February 9, 2014, through December 31, 2015, Employer A
does not change the eligibility requirements for the group health
plan (including not amending it to eliminate its existing health
coverage for dependents) and continues to make an employer
contribution of $300 per month toward the cost of employee-only
coverage that provides minimum value. Employer A certifies in a
timely manner as to its eligibility for the transition relief; Employer
A is eligible for the transition relief.
2. 2015 Transition Relief for Calculation of Assessable
Payments Under Section 4980H(a) for ALEs with 100 or
More Full-Time Employees, Including Full-Time Equivalent
Employees (100 or More Transition Relief). As 2015
transition relief, for each month in 2015 (and, in addition, for the
portion of the 2015 plan year that ends in 2016 if the employer
has a non-calendar year plan), if an employer is an ALE or is part
of an Aggregated ALE Group that had 100 or more full-time
employees (including full-time equivalent employees) on
business days in 2014, and is subject to an assessable payment
under section 4980H(a), the assessable payment under section
4980H(a) is calculated by reducing the employer’s number of
full-time employees by that employer’s allocable share of 80
(rather than by the employer’s standard allocable share of 30).
For the rules on how the 80 employee reduction is allocated
among the employers in an Aggregated ALE Group, see
Regulations section 54.4980H-4(e).

during that period, including, if applicable, the required
employee contribution.

2015 Section 4980H Transition Relief Based on
Number of Full-Time Employees (Form 1094-C,
Line 22, Box C, and Form 1094-C, Lines 23-35,
Column (e))

An employer may be eligible for one of the two types of 2015
transition relief under section 4980H based on the employer’s
number of full-time employees (and full-time equivalent
employees) if certain conditions described below are met. One
of these two types of 2015 transition relief under section 4980H
is for employers with 50 to 99 full-time employees and the other
type of relief is for employers with 100 or more full-time
employees (in each case including full-time equivalent
employees). Eligibility for this transition relief is reported on Form
1094-C, line 22, box C, and the specific form of relief for which
the employer is eligible must be reported on Form 1094-C, Lines
23-35, column (e), using either code A (50-99 Transition Relief)
or code B (100 or more Transition Relief). An employer eligible
for this relief is still subject to the Forms 1094-C and 1095-C
reporting requirements for 2015 with respect to its full-time
employees.
For purposes of determining eligibility for either of these types
of section 4980H transition relief, the number of full-time
employees (including full-time equivalent employees) for 2015 is
determined in the same way that an employer determines
whether it is an ALE (including using employment and hours of
service data from 2014) and is calculated for the Aggregated
ALE Group (rather than for each employer).
1. 2015 Section 4980H Transition Relief for ALEs with
Fewer Than 100 Full-Time Employees, Including Full-Time
Equivalent Employees (50-99 Transition Relief). For an
employer that is eligible for this 2015 transition relief, no
assessable payment under section 4980H(a) or (b) will apply for
any calendar month during 2015 and, if the employer has a
non-calendar-year plan, will not apply for the portion of the 2015
plan year that falls in 2016. To certify that an employer is eligible
for this transition relief it must have met the following conditions:
The employer is an ALE or is part of an Aggregated ALE
Group that had 50 to 99 full-time employees, including full-time
equivalent employees, on business days in 2014;
During the period of February 9, 2014, through December 31,
2014, the ALE or the Aggregated ALE Group of which the
employer is a member did not reduce the size of its workforce or
reduce the overall hours of service of its employees in order to
qualify for the transition relief; and
During the period of February 9, 2014, through December 31,
2015, (or, if the employer has a non-calendar-year plan(s)),
ending on the last day of the 2015 plan year) the ALE or
Aggregated ALE Group of which the employer is a member does
not eliminate or materially reduce the health coverage, if any, it
offered as of February 9, 2014.

2015 Section 4980H(a) Transition Relief if an
Offer of Health Coverage is Made to at least 70
Percent of Full-Time Employees (Form 1094-C,
Lines 23–35, Column (a))

For each calendar month during 2015 (and any calendar months
during the 2015 plan year that occur in 2016, if the employer has
a non-calendar year plan), an employer that offers health
coverage to at least 70 percent of its full-time employees (and
their dependents) may, on Form 1094-C, lines 23–35, column
(a), enter an “X” in the “Yes” checkbox either for “All 12 Months”
or for the month(s) during which it met that 70-percent threshold,
as applicable.

2015 Section 4980H(a) Transition Relief for
Certain Arrangements that do not Offer Health
Coverage for Dependents (Form 1094-C, Lines
23–35, Column (a))

For the 2014 and 2015 plan years, for an employee who was not
offered dependent health coverage during the 2013 or 2014 plan
years, an employer may treat, solely for purposes of section
4980H, an offer of health coverage to a full-time employee but
not his or her dependents, as an offer of health coverage to the
full-time employee and his or her dependents, if the employer
takes steps during the 2014 or 2015 plan year (or both) to
extend coverage under the plan to dependents not offered
coverage during the 2013 or 2014 plan year (or both). An
employer using this transition relief for a calendar year is not
eligible to report using the Qualifying Offer Method (or the
Qualifying Offer Transition Relief Method) for that calendar year.

Example. As of February 9, 2014, Employer A (which is an
ALE with only one ALE Member) sponsors a group health plan
with a calendar year plan year under which 40 of its full-time
employees are offered health coverage that provides minimum
value and with an employer contribution of $300 per month for
employee-only coverage. The offer of health coverage is
affordable for some, but not all, of Employer A’s full-time
employees. During the period from February 9, 2014, through
December 31, 2014, two of Employer A’s employees voluntarily
terminate employment and Employer A terminates three
employees because of the non-renewal of a customer contract
but does not otherwise reduce the size of its workforce or reduce
any employee’s hours of service. Had those five employees
continued in employment throughout 2014, the employer would

2015 Section 4980H(a) Transition Relief for
Employers with Non-Calendar Year Plans (Form
1094-C, Lines 23–35, Column (a))
An employer that sponsored a non-calendar year health plan as
of December 27, 2012, (or two or more health plans with the

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2015 Section 4980H(b) Transition Relief for
Employers with Non-Calendar Year Plans (Form
1095-C, Line 16, Code 2I)

same non-calendar year plan year) may be eligible for certain
transition relief. The relief would apply for some or all of its
employees for the period during 2015 before the beginning of
the 2015 plan year (for example, the months January, February,
and March 2015 for an employer with a plan year starting April 1,
2015). In certain circumstances described below, this relief
applies so that an employee and his or her dependents may be
treated for purposes of section 4980H(a) as offered minimum
essential coverage during that period even if not actually offered
minimum essential coverage. An employer that is eligible for the
relief may treat the employee and his or her dependents as
offered minimum essential coverage for purposes of Form
1094-C, Part III, column (a), (and specifically for purposes of
determining whether to enter an “X” in the “Yes” or “No”
checkbox for the months during that period). See instructions for
2015 Section 4980H(b) Transition Relief for Employers with
Non-Calendar Year Plans (Form 1095-C, line 16), later.

Relief under section 4980H(b) for an employee for the months in
2015 prior to the 2015 plan year is available for an employer that
met the conditions described above under 2015 Section
4980H(a) Transition Relief for Employers with Non-Calendar
Year Plans (Form 1094-C, Lines 23-35, column (a)), if the
coverage offered to the employee by the beginning of the 2015
plan year was affordable and provided minimum value. In that
case, the employee may be treated for purposes of section
4980H(b) as offered minimum essential coverage providing
minimum value that is affordable for the months prior to the 2015
plan year. An employer that meets these requirements reports its
eligibility on the Form 1095-C, line 16, code 2I for each full-time
employee for which the employer is eligible for this relief.

Treatment of full-time employees eligible for the non-calendar year plan. For an employee of the employer (whenever
hired) who was eligible for health coverage under that
non-calendar year health plan effective beginning on the first day
of the 2015 plan year under the eligibility terms of the plan as in
effect on February 9, 2014, for purposes of Form 1094-C, Part
III, column (a), the employer may treat the employee (and his or
her dependents) as having been offered coverage for the
months in 2015 prior to the 2015 plan year if the employee was
offered health coverage no later than the first day of the 2015
plan year.

Section 4980H Transition Relief for Health
Coverage for January 2015 (Form 1094-C, Lines
23-24, Column (a) and Form 1095-C, Line 14)

Solely for January 2015, if an employer offers health coverage to
an employee no later than the first day of the first payroll period
that begins in January 2015, the employer is treated as having
offered health coverage for January 2015. An employer that is
eligible for this transition relief for an employee for January 2015
should treat that employee as having been offered minimum
essential coverage for January 2015 for purposes of Form
1094-C, line 23 or 24 (whichever is applicable), column (a). An
employer that is eligible for this transition relief would report on
Form 1095-C, line 14, that it did not offer its employee health
coverage for the month of January (using code 1H). However, it
would report on Line 16 using code 2A that it is eligible for this
relief with respect to the employee if the coverage offered was
affordable for purposes of the employer shared responsibility
provisions under section 4980H and provided minimum value.

Treatment of full-time employees not eligible for the
non-calendar year plan—Significant percentage transition
guidance (all employees). If an employer otherwise eligible
for the relief described in this section:
1. had at least 1/4 of its employees enrolled in health
coverage under the non-calendar year plan as of any date in the
12 months ending on February 9, 2014, or
2. offered health coverage under the non-calendar year plan
to at least 1/3 of its employees during the open enrollment period
that ended most recently before February 9, 2014.

Interim Guidance Regarding Multiemployer Arrangements.
For a description of the treatment of certain coverage provided
through a multiemployer arrangement, see offer of health
coverage in the Definitions section.

Then purposes of Form 1094-C, Part III, column (a), Minimum
Essential Coverage Offer Indicator, the employer may treat an
employee who was not offered coverage for the months in 2015
prior to the 2015 plan year (and his or her dependents) as having
been offered coverage for that period if the employee was
offered health coverage no later than the first day of the 2015
plan year.

Privacy Act and Paperwork Reduction Act Notice. We ask
for the information on these forms to carry out the Internal
Revenue laws of the United States and the Patient Protection
and Affordable Care Act. Our legal right to ask for the
information on this form is Internal Revenue Code sections 6055,
6056, 4980H and their regulations. We request it to confirm that
you are providing your employees offers of, and enrollment in,
health coverage and to determine the employer shared
responsibility payments and eligiiblity of your employees for
premium tax credits. You are not required to provide the
information requested on these forms for 2014. If you do not
provide this information, we may be unable to determine whether
your employees are entitled to premium tax credits. Providing
false or fraudulent information may subject you to penalties. We
may disclose this information to the Department of Justice for
civil or criminal litigation and to cities, states, and the District of
Columbia for use in administering their tax laws. We may also
disclose this information to other countries under a tax treaty, to
Federal and state agencies to enforce Federal nontax criminal
laws, or to Federal law enforcement and intelligence agencies to
combat terrorism.

Treatment of full-time employees not eligible for the
non-calendar year plan—Significant percentage transition
guidance (full-time employees). If an employer otherwise
eligible for the relief in this section:
1. had at least 1/3 of its full-time employees enrolled in
health coverage under the non-calendar year plan as of any date
in the 12 months ending on February 9, 2014, or
2. offered health coverage under the plan to at least 1/2 of
its full-time employees during the open enrollment period that
ended most recently before February 9, 2014.
Then purposes of Form 1094-C, Part III, column (a), Minimum
Essential Coverage Offer Indicator, the employer may treat an
employee (and his or her dependents) as having been offered
coverage for the months in 2015 prior to the 2015 plan year if the
employee was offered health coverage no later than the first day
of the 2015 plan year.

Instructions for Forms 1094-C and 1095-C (2014)

You are not required to provide the information requested on
a form that is subject to the Paperwork Reduction Act unless the
form displays a valid OMB control number. Books or records
relating to a form or its instructions must be retained as long as
their contents may become material in the administration of any
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Fileid: … 094C&1095C/2014/A/XML/Cycle02/source

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The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

internal revenue law. Generally, tax returns and return
information are confidential, as required by section 6103.
The time needed to complete and file this form will vary
depending on individual circumstances. The estimated average
time is:
Form 1094–C . . . . . . . . . . . . . . .

4 hrs.

Form 1095–C . . . . . . . . . . . . . . .

12 min.

If you have comments concerning the accuracy of these time
estimates or suggestions for making this form simpler, we would
be happy to hear from you. You can write to the Internal
Revenue Service, Tax Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6526,
Washington, DC 20224. Do not send the form to this office.
Instead, see Where To File, earlier.

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Instructions for Forms 1094-C and 1095-C (2014)