Form 1094-C

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2014 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-ProvisionsHome. For the final regulations under section 6056, 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, 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, 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, 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
Oct 29, 2014

Department of the Treasury
Internal Revenue Service

employer owes payments under the employer shared
responsibility provisions under section 4980H. Form
1095-C is also used in determining eligibility of employees
for premium tax credits.
Employers that offer employer-sponsored self-insured
coverage also use Form 1095-C to report information to
the IRS and to taxpayers about individuals who are
covered by minimum essential coverage under the
employer plan and therefore are not liable for the
individual shared responsibility payments.
The employer is required to file Forms 1094-C and
1095-C with the IRS and to furnish a copy of Form 1095-C
to the employee.

Who Must File

An employer subject to the employer shared responsibility
provisions under section 4980H must file one or more
Forms 1094-C (including an 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. 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.
An employer that provides health coverage through an
employer-sponsored self-insured health plan must also
complete Form 1095-C, Part III, for any individual
(including any full-time employee, non-full-time employee,
employee family members, and others) who enrolled in
the self-insured health plan. If an employer offers health
coverage through a health plan, and some of the
enrollment options under the plan are
employer-sponsored self-insured health arrangements
while others are not (for example, some of the enrollment
options are insured arrangements), the employer must
only complete Form 1095-C, Part III, for the employees
who enrolled in the self-insured enrollment option(s) under
the plan.
An employer that provides health coverage through an
employer-sponsored self-insured health plan must
complete Form 1095-C, Parts I 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 is a full-time employee for
any month of the calendar year, the employer must also
complete Part II. If, for all 12 months of the calendar year,
the employee is not a full-time employee, the employer
must complete only Part II, line 14, by entering code 1G in
the “All 12 Months” column.

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day is any day that is not a Saturday, Sunday, or legal
holiday.

If an employer is providing health coverage 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 will provide
the information about their health coverage to any enrolled
employees, and the employer should not complete Form
1095-C, Part III, for those employees.

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.

An employer that provides employer-sponsored
self-insured health coverage but is not subject to the
employer shared responsibility provisions under section
4980H, is not required to file Forms 1094-C and 1095-C
and reports instead on Forms 1094-B and 1095-B for
employees who enrolled in the employer-sponsored
self-insured health coverage.

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).
Form 1095-C must be furnished to the individual by
January 31 of the year following the year to which the
return relates. The first Forms 1095-C are due to
individuals by February 1, 2016.

Authoritative Transmittal for Employers Filing
Multiple Forms 1094-C

Where To File

A Form 1094-C must be attached to any Forms 1095-C
filed by an employer. An employer may choose to submit
multiple Forms 1094-C, each accompanied by Forms
1095-C for some of its employees, provided that, in
combination, Forms 1095-C are filed for each employee
for whom the employer is required to file. An employer
must file a single Form 1094-C reporting aggregate
employer-level data for all full-time employees of the
employer and identify the form, on line 19 of Part II, as the
Authoritative Transmittal. One Authoritative Transmittal
must be filed for each employer, even in cases in which
multiple Forms 1094-C are filed by and on behalf of the
employer (including in the case of a Governmental Unit
that has delegated its reporting responsibilities for some
of its employees to another Governmental Unit). For
example, if an employer has prepared 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 all full-time employees of the
employer (the employees of both divisions).

Send all information returns filed on paper to the following:
If your principal business,
office or agency, or legal
residence in the case of an
individual, is located in:
▼

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

Use the following address:
▼

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

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

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

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

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

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.

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.

When To File

You will meet the requirement to file 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

Pub. 5165, Affordable Care Act (ACA) Information
Returns (AIR) Guide for Software Developers and
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Instructions for Forms 1094-C and 1095-C (2014)

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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.

Specific Instructions for Form 1094-C
Part I—Applicable Large Employer Member
(ALE Member)
Line 1. Enter employer's name.
Line 2. Enter the employer’s employer identification
number (EIN). A social security number (SSN) may not be
entered in lieu of an EIN. Enter the 9-digit EIN including
the dash.

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

If you are filing Form 1094-C, a valid EIN is
required at the time it is filed. If a valid EIN is not
CAUTION
provided, 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.

Corrected Forms 1094-C and 1095-C

!

Reserved.

Furnishing Forms 1095-C To Employees

You will meet the requirement to file 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.

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.

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.

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

For more information on alternative furnishing methods
for employers, see the Qualifying Offer Method and the
Qualifying Offer Method Transition Relief for 2015, later.

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.

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. The filing employer’s
EIN may not be truncated on either the statement
furnished to the employee or the forms filed with the IRS.

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. A social security number
(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.
CAUTION
If a valid EIN is 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.

!

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.
Consent to furnish statement electronically. The
requirement to obtain affirmative consent to furnish a
statement electronically ensures that statements are sent
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.

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.
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.

Part II—ALE Member Information
Line 19. If you are using this Form 1094-C transmittal as
the Authoritative Transmittal to report aggregate
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indicate that the employee received a Qualifying Offer for
all 12 months. Use of this method is optional and an
employer may, rather than report using this method and
the Qualifying Offer code 1A , 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
and also report the dollar amount required as an
employee contribution for the lowest-cost employee-only
coverage providing minimum value.

employer-level data for the employer, check the box on
line 19 and continue completing Part II.
There must be only one Authoritative Transmittal filed
for each employer. If only one Form 1094-C is being filed
for the employer, that 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 this 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.

If the employer is eligible to use the Qualifying
Offer Method, it may use the Qualifying Offer
code 1A 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 months. However,
the employer must furnish a copy of Form 1095-C to any
employee who did not receive a Qualifying Offer for all 12
months, unless the Qualifying Offer Method Transition
Relief applies.

TIP

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. If this is not the
Authoritative Transmittal for the employer, do not
complete lines 20–22, Parts III or IV. Sign Form 1094-C.

Alternative Method of Furnishing 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 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.
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.
See Pub. 974, Premium Tax Credit (PTC), for more
information on eligibility for the premium tax credit.
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 2015. For
the 2015 calendar year, to be eligible to use the Qualifying
Offer Method Transition Relief the employer must certify
that it made a Qualifying Offer for one or more months of
calendar year 2015 to at least 95% of its full-time
employees.
If an employer uses this method, it must not provide on
Form 1095-C, line 15, the dollar amount required as an
employee contribution for the lowest-cost employee-only
coverage providing minimum value and instead must use
either the Qualifying Offer code 1A or the Qualifying Offer
Method Transition Relief code 1I on Form 1095-C, line 14,
to indicate the months in 2015 for which the employer is
eligible for the Qualifying Offer Method Transition Relief
code 1I or the months for which the employee received a
Qualifying Offer code 1A. For any months for which the
employee received a Qualifying Offer, the employer must
report using the Qualifying Offer code 1A to indicate that
the employee received a Qualifying Offer for that month.
For any month, use of this method is optional, and an
employer may, rather than report using this method and
the Qualifying Offer code 1A or the Qualifying Offer
Method Transition Relief code 1I, report on line 14 the

Line 20. Enter the total number of Forms 1095-C that will
be filed by and/or on behalf of the employer. This includes
Forms 1095-C for the employer’s full-time employees that
are filed with this transmittal, those that will be filed with
another transmittal filed by or on behalf of the employer,
and Forms 1095-C filed for non-full-time employees who
enroll in the employer’s employer-sponsored self-insured
health plan.
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,” you must also complete
the “Aggregated Group Indicator” in Part III, column (d),
and 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. See the description of the Offer Methods
and Section 4980H Transition Relief, later.
Note. For 2014, 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.
A. Qualifying Offer Method. Check this box if the
employer is eligible to use and is using the Qualifying
Offer Method for one or more full-time employees. To be
eligible to use the Qualifying Offer Method, the employer
must certify that, for all months during the year in which
the employee was a full-time employee for whom a
section 4980H employer shared responsibility payment
could apply, the employer made a Qualifying Offer.
If the employer uses this method, it must not provide on
Form 1095-C, line 15, the dollar amount required as an
employee contribution for the lowest-cost employee-only
coverage providing minimum value. It instead must use
the Qualifying Offer code 1A on Form 1095-C, line 14, to
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Part III—ALE Member Information—Monthly
(Line 23-35)

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 required as
an employee contribution for the lowest-cost
employee-only coverage providing minimum value.
Alternative Furnishing Methods 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.
Employer name, address, and EIN.
Contact name and telephone number.
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.
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.
C. Section 4980H Transition Relief. Check this box if
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. 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 Relief Indicator, to indicate
the type of section 4980H transition relief for which it is
eligible.
D. 98% Offer Method. Select 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 and their dependents for
whom it is filing a Form 1095-C employee statement. 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.)

Column (a) Minimum Essential Coverage Offer Indicator. If the employer offered minimum essential
coverage under an eligible employer-sponsored plan 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”. 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,
or enter “X” in the “All 12 Months” box on line 23 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. However, an employer that did
not offer minimum essential coverage to at least 95% of its
full-time employees and their dependents but is entitled to
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.
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.
For purposes of column (a), if the employer
TIP offered minimum essential coverage to all but five
of its full-time employees and their dependents,
and if five is greater 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).
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 include 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.)
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).
Column (c) Total Employee Count for ALE Member.
Enter the total number of employees, including full-time
employees and non-full-time employees, for each
calendar month. An employer must choose to use either
the first day of each month or the last day of each month
to determine the number of employees per month and
must use the same day (first or last day of the month) for

Note. If an employer uses this method, it is not required
to complete the “Full-Time Employee Count” in Part III,
column (b).
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If you are filing Form 1095-C, a valid EIN is
required at the time it is filed. If a valid EIN is not
CAUTION
provided, the Form 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.

all months of the year. If the total number of employees
was the same for every month of the entire calendar year,
enter that number in line 23 “All 12 months.” If the number
of employees for any month is zero, enter 0.

!

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 during each month of the calendar year the
employer was a member of an Aggregated ALE Group,
enter “X” in the “All 12 months” box. 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.

Lines 9 and 11–13. Enter the ALE Member’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.
Line 10. Enter the telephone number of the person to
contact whom the recipient may call about the information
reported on the form.

Column (e) Section 4980H Transition Relief Indicator.
If the employer certifies by selecting box D 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.

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.
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 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) under Form 1094-C, Part III, column
(a).

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 (as reported in Part III, column (b)) 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 the members in descending order listing
first the member with the 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
the Aggregated ALE Group

Indicator Codes for Employee Offer and Coverage
(Form 1095-C, Line 14)
Code Series 1, Offer of Coverage.
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).

Specific Instructions for Form 1095-C
Part I—Employee
Line 1. Enter the name of the employee.
Line 2. Enter the 9-digit SSN of the employee with the
dashes.

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.

TIP

Lines 3–6. Enter the employee’s complete address
(including apartment no., if applicable).

Part I—Applicable Large Employer Member
(Employer)

1B. Minimum essential coverage providing minimum
value offered to employee only.

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.
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2A. Employee not employed during the month. Enter
code 2A if the employee was not employed on any day of
the month. Do not use code 2A for a month if the
individual is an employee of the employer on any day of
the month. Do not use this code 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.
2C. Employee enrolled in coverage offered. Enter code
2C for any month in which the employee enrolled in health
coverage offered by the employer, regardless of whether
any other code in Code Series 2 might also apply.

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. Enter code 1G in the “All 12
Months” box and do not complete the monthly boxes.
1H. No offer of coverage (employee not offered any
health coverage or employee offered coverage that is not
minimum essential coverage).
1I. Qualified Offer Transition Relief 2015: Employee
(and spouse or dependents) received no offer of
coverage, received an offer that is not a qualified offer, or
received a qualified offer for less than 12 months.

Note. If the employee enrolled in the minimum essential
coverage offered for the month, enter code 2C (employee
enrolled in coverage offered), and not any other in Code
Series 2 that might also apply.
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 in the
Definitions under Offer of Health Coverage.
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).
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).
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).

Line 15. Complete line 15 only if the coverage offered to
the employee provided minimum value and 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
not required to contribute any amount towards the
premium, enter “0.00.” If the employee share of the
lowest-cost monthly amount was the same amount for all
12 calendar months, 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. If the employer did not offer
health coverage, or it offered health coverage that was not
minimum essential coverage or did not provide minimum
value, do not complete this line.
Line 16. For each calendar month, enter the applicable
code from Series 2, but 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
the “All 12 Months” box and do not complete individual
calendar month boxes. If none of the codes apply for a
calendar month, leave the line blank for that month. These
codes indicate that under a rule or safe harbor the
employer will not be subject to an assessable payment
under section 4980H(b) for the month, or that the health
coverage offered will be treated as affordable for
purposes of section 4980H(b).
Code Series 2—Section 4980H Safe Harbor Codes
and Other Relief for Employers
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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.

Aggregated ALE Group. An Aggregated ALE Group
refers to a group of ALE Members treated as a single
employer under 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.

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 enrolled. This part must be
completed by an employer offering self-insured health
coverage for any employee who enrolled in the coverage,
regardless of whether the employee is a full-time
employee. 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.

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.

For this purpose, employer-sponsored self-insured
health coverage does not include coverage under a
multiemployer plan.
Employers that offer employer-sponsored
TIP self-insured health coverage to non-employees
(for example, non-employee directors) who enroll
in the coverage will complete Forms 1094-B and 1095-B,
rather than Part III, for those individuals.

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.

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 III.

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.

Column (a). Enter the name of each covered individual.
Column (b). Enter the 9-digit SSN for each covered
individual with the dashes.
Column (c). Enter a date of birth (MM/DD/YYYY) for the
covered individual only if column (b) is blank.

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 (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.

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.

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
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appropriately designated for purposes of these reporting
requirements.

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, 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).

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 group
market, or (4) a self-insured group health plan for
employees.

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 of 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.

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 2-percent S
corporation shareholder, 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 can treat one of the
employers as the employer of that employee for that
calendar month and if the employers do not select one
employer, or select in an inconsistent manner, the IRS will
select an employer to be treated as the employer of that
employee for that calendar month. See Publication 15-A,
Employer’s Supplemental Tax Guide, for more information
on determining who is an employee.

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 of 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, see Regulations sections 54.4980H-1(a)(21)
and 54.4980H-3.

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

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 for all twelve months of the calendar
year.
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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 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.
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.
Minimum value. A plan provides minimum value if the
plan pays at least 60 percent of the costs of benefits.
Offer of health coverage. An offer to an employee
providing 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.
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, 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, the employer
will still have offered the employee health coverage for the
month if the employee would have been offered health
coverage for the entire month had the employee been
employed for the entire month.
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.
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. For more information, see
section XV.E of the preamble to the final section 4980H
regulations.

TIP

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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.

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).

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 reflect the health
coverage offered to that employee (if any) during that
period, including, if applicable, the required employee
contribution.
An employer eligible for this relief is still subject to the
Forms 1094-C and 1095-C reporting requirements for
2015.

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).
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

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

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 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

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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).

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.

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 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.
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.
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,
for 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.
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, for
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.

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

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,
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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.

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 offered its
employee health coverage for the month of January.
There is not a specific indicator code to reflect this
transition relief.

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.
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 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:

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

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

Recordkeeping . . . . . . . . . . . . . . . .

.

Learning about the law or the
form . . . . . . . . . . . . . . . . . . . . . . . .

.

Preparing the form . . . . . . . . . . . .

.

Copying, assembling, and
sending the form to the IRS . . . . . .

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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