Form 1094-C

Information Reporting by Applicable Large Employers on Health Insurance Coverage Offered Under Employer-Sponsored Plans

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2251 can be found here:

Documents and Forms

Document Name Document Type
Form Form 1094-C Form 1094-C Form
i1094-c_and_1095_c--2016-00-00.pdf www.IRS.gov Instruction
Form 1094-C Transmittal of Employer-Provided Health Insurance Offer f1094-c--2016-00-00.pdf www.IRS.gov Form
Notice 2011-36.pdf Notice 2011-36 IC Document
Notice 2011-73.pdf Notice 2011-73 IC Document
Notice 2012-17.pdf Notice 2012-17 IC Document
Notice 2012-58.pdf Notice 2012-58 IC Document
REG-136630-12 NPRM.pdf REG-138006-12 IC Document

Information Collection (IC) Details

IC Title:	Form 1094-C	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 26 CFR 301.6011-9 26 CFR 301.6056-1 26 CFR 301.6056-2

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Form 1094-C	Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns	f1094-c--2016-00-00.pdf	www.IRS.gov	Yes	Yes	Fillable Fileable
Instruction			i1094-c_and_1095_c--2016-00-00.pdf	www.IRS.gov	Yes	Yes	Fillable Printable

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	15,000	15,000
Annual IC Time Burden (Hours)	60,000	60,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.