Caution: DRAFT—NOT FOR FILING

1 Caution: DRAFT NOT FOR FILING This is an early release draft of an IRS tax form , instructions, or publication, which the IRS is providing for your information as a courtesy. Do not file draft forms. Also, do not rely on draft forms, instructions, and publications for FILING . We generally do not release drafts of forms until we believe we have incorporated all changes. However, unexpected issues sometimes arise, or legislation is passed, necessitating a change to a draft form . In addition, forms generally are subject to OMB approval before they can be officially released.

2 Drafts of instructions and publications usually have at least some changes before being officially released. Early release drafts are at , and may remain there even after the final release is posted at All information about all forms, instructions, and pubs is at Almost every form and publication also has its own page on For example, the form 1040 page is at ; the Publication 17 page is at ; the form W-4 page is at ; and the Schedule A ( form 1040) page is at If typing in a link above instead of clicking on it, be sure to type the link into the address bar of your browser, not in a Search box.

3 Note that these are friendly shortcut links that will automatically go to the actual link for the page. If you wish, you can submit comments about draft or final forms, instructions, or publications at We cannot respond to all comments due to the high volume we receive. Please note that we may not be able to consider many suggestions until the subsequent revision of the product. DO NOT FILEJuly 24, 2018 DRAFT AS OF 600118 form 1095-CDepartment of the Treasury internal revenue ServiceEmployer- provided Health Insurance Offer and Coverage Do not attach to your tax return.

4 Keep for your records. Go to for instructions and the latest No. 1545-22512018 Part IEmployee 1 Name of employee (first name, middle initial, last name) 2 Social security number (SSN) 3 Street address (including apartment no.) 4 City or town5 State or province 6 Country and ZIP or foreign postal codeApplicable Large Employer Member (Employer) 7 Name of employer 8 Employer identification number (EIN) 9 Street address (including room or suite no.) 10 Contact telephone number11 City or town12 State or province13 Country and ZIP or foreign postal codePart IIEmployee Offer of CoveragePlan Start Month (enter 2-digit number).

5 All 12 MonthsJanFebMarAprMayJuneJulyAugSeptOctN ovDec14 Offer of Coverage (enter required code)15 Employee Required Contribution (see instructions) $$$$$$$$$$$$$16 Section 4980H Safe Harbor and Other Relief (enter code, if applicable)Part IIIC overed Individuals If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.(a) Name of covered individual(s) First name, middle initial, last name(b) SSN or other TIN(c) DOB (if SSN or other TIN is not available)(d) Covered all 12 months(e) Months of Coverage JanFebMarAprMayJuneJulyAugSeptOctNovDec1 71819202122 For Privacy Act and Paperwork Reduction Act Notice, see separate No.

6 60705 MForm 1095-C (2018)DO NOT FILEJuly 24, 2018 DRAFT AS OF 600216 form 1095-C (2018) Page 2 Instructions for RecipientYou are receiving this form 1095-C because your employer is an Applicable Large Employer subject to the employer shared responsibility provision in the Affordable Care Act. This form 1095-C includes information about the health insurance coverage offered to you by your employer. form 1095-C, Part II, includes information about the coverage, if any, your employer offered to you and your spouse and dependent(s). If you purchased health insurance coverage through the Health Insurance Marketplace and wish to claim the premium tax credit, this information will assist you in determining whether you are eligible.

7 For more information about the premium tax credit, see Pub. 974, Premium Tax Credit (PTC). You may receive multiple Forms 1095-C if you had multiple employers during the year that were Applicable Large employers (for example, you left employment with one Applicable Large Employer and began a new position of employment with another Applicable Large Employer). In that situation, each form 1095-C would have information only about the health insurance coverage offered to you by the employer identified on the form . If your employer is not an Applicable Large Employer, it is not required to furnish you a form 1095-C providing information about the health coverage it offered.

8 In addition, if you, or any other individual who is offered health coverage because of their relationship to you (referred to here as family members), enrolled in your employer's health plan and that plan is a type of plan referred to as a "self-insured" plan, form 1095-C, Part III, provides information to assist you in completing your income tax return by showing you or those family members had qualifying health coverage (referred to as "minimum essential coverage") for some or all months during the your employer provided you or a family member health coverage through an insured health plan or in another manner, the issuer of the insurance or the sponsor of the plan providing the coverage will furnish you information about the coverage separately on form 1095-B, Health Coverage.

9 Similarly, if you or a family member obtained minimum essential coverage from another source, such as a government-sponsored program, an individual market plan, or miscellaneous coverage designated by the Department of Health and Human services , the provider of that coverage will furnish you information about that coverage on form 1095-B. If you or a family member enrolled in a qualified health plan through a Health Insurance Marketplace, the Health Insurance Marketplace will report information about that coverage on form 1095-A, Health Insurance Marketplace are required to furnish form 1095-C only to the employee.

10 As the recipient of this form 1095-C, you should provide a copy to any family members covered under a self-insured employer-sponsored plan listed in Part III if they request it for their information. For additional information about the tax provisions of the Affordable Care Act (ACA), including the individual shared responsibility provisions, the premium tax credit, and the employer shared responsibility provisions, see or call the IRS Healthcare Hotline for ACA questions (1-800-919-0452).Part I. EmployeeLines 1 6. Part I, lines 1 6, reports information about you, the 2.