Transcription of 2015 Form 1094-C
1 120116 CORRECTEDForm1094-CDepartment of the Treasury internal revenue ServiceTransmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns Information about Form 1094-C and its separate instructions is at No. 1545-22512015 Part IApplicable Large Employer Member (ALE Member)1 Name of ALE Member (Employer) 2 Employer identification number (EIN)3 Street address (including room or suite no.)4 City or town5 State or province6 Country and ZIP or foreign postal code7 Name of person to contact8 Contact telephone number9 Name of Designated Government Entity (only if applicable) 10 Employer identification number (EIN)11 Street address (including room or suite no.)
2 12 City or town13 State or province14 Country and ZIP or foreign postal code15 Name of person to contact 16 Contact telephone numberFor Official Use Only17 Reserved ..18 Total number of Forms 1095-C submitted with this transmittal .. Part IIALE Member Information19 Is this the authoritative transmittal for this ALE Member? If Yes, check the box and continue. If No, see instructions ..20 Total number of Forms 1095-C filed by and/or on behalf of ALE 21 Is ALE Member a member of an Aggregated ALE Group? ..YesNoIf No, do not complete Part IV. 22 Certifications of Eligibility (select all that apply): A. Qualifying Offer MethodB.
3 Qualifying Offer Method Transition ReliefC. Section 4980H Transition ReliefD. 98% Offer MethodUnder 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. Signature Title DateFor Privacy Act and Paperwork Reduction Act Notice, see separate No. 61571 AForm 1094-C (2015)120216 Form 1094-C (2015)Page 2 Part IIIALE Member Information Monthly(a) Minimum Essential Coverage Offer Indicator YesNo(b) Full-Time Employee Count for ALE Member(c) Total Employee Count for ALE Member(d) Aggregated Group Indicator (e) Section 4980H Transition Relief Indicator 23 All 12 Months24 Jan25 Feb26 Mar27 Apr28 May29 June30 July31 Aug32 Sept33 Oct34 Nov35 DecForm 1094-C (2015)120315 Form 1094-C (2015)
4 Page 3 Part IVOther ALE Members of Aggregated ALE GroupEnter the names and EINs of Other ALE Members of the Aggregated ALE Group (who were members at any time during the calendar year).NameEIN363738394041424344454647484 950 NameEIN515253545556575859606162636465 Form 1094-C (2015)
