Form 1094-B Transmittal of Health Coverage Information Returns

Form

1094-B

Department of the Treasury
Internal Revenue Service
1 Filer's name

3 Name of person to contact

5 Street address (including room or suite no.)

7 State or province

DRAFT AS OF
July 27, 2017
DO NOT FILE

110116

Transmittal of Health Coverage Information Returns
▶ Go

OMB No. 1545-2252

2017

to www.irs.gov/Form1094B for instructions and the latest information.

9 Total number of Forms 1095-B submitted with this transmittal .

2 Employer identification number (EIN)

4 Contact telephone number

6 City or town

For Official Use Only

8 Country and ZIP or foreign postal code

.

.

.

.

.

.

.

.

.

.

.

.

.

▶

Under penalties of perjury, I declare that I have examined this return and accompanying documents, and to the best of my knowledge and belief, they are true, correct, and complete.

▲

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

▲

▲

Signature

Title

Cat. No. 61570P

Date
Form

1094-B (2017)