Form 1095-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⚠️ Notice: This information collection may be referencing outdated material.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 1095-C Form 1095-C Form
i1094-c_and_1095_c--2016-00-00.pdf www.irs.gov Instruction
Form 1095-C Employer-Provided Health Insurance Offer and Coverage f1095-c--2016-00-00.pdf www.irs.gov Form

Information Collection (IC) Details

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:

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 %

	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

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.