Information Collection

Form 1095-C

IC 214082 under ICR 201701-1545-021 · OMB 1545-2251.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form 1095-C Employer-Provided Health Insurance Offer and Coverage Form 1095-C	Form
i1094-c_and_1095_c--2016-00-00.pdf	Instruction
Form 1095-C Employer-Provided Health Insurance Offer and Coverage f1095-c--2016-00-00.pdf	Form

IC Title:

Form 1095-C

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Form 1095-C	Employer-Provided Health Insurance Offer and Coverage	f1095-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 Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,850,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,850,000	3,850,000
Annual IC Time Burden (Hours)	750,000	750,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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