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2017 Form 1095-B - Internal Revenue Service

560116. form 1095-B Health coverage VOID OMB No. 1545-2252. Department of the Treasury Internal Revenue Service . Do not attach to your tax return. Keep for your records. Go to for instructions and the latest information. CORRECTED 2017. Part I Responsible Individual 1 Name of responsible individual 2 Social security number (SSN) or other TIN 3 Date of birth (if SSN or other TIN is not available). 4 Street address (including apartment no.) 5 City or town 6 State or province 7 Country and ZIP or foreign postal code 9 Reserved 8 Enter letter identifying Origin of the Health coverage (see instructions for codes).

Form 1095-B Department of the Treasury 2017 Internal Revenue Service. Health Coverage Do not attach to your tax return. Keep for your records. Go to

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