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1 Note: The draft you are looking for begins on the next page. 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. Do not file draft forms and do not rely on draft forms, instructions, and publications for FILING . We do not release draft forms until we believe we have incorporated all changes (except when explicitly stated on this coversheet). However, unexpected issues occasionally arise, or legislation is passed in this case, we will post a new draft of the form to alert users that changes were made to the previously posted draft .

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4 If you have comments on reducing paperwork and respondent (filer) burden, with respect to draft or final forms, please respond to the relevant information collection through the Federal Register process; for more info, click here. DO NOT FILEMay 24, 2021 draft AS OF120118 CORRECTEDForm1094-CDepartment of the Treasury Internal Revenue ServiceTransmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns Go to for instructions and the latest No. 1545-22512021 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.)

5 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.)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?

6 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 Member .. 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. ReservedC. ReservedD. 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.

7 Signature Title DateFor Privacy Act and Paperwork Reduction Act Notice, see separate No. 61571 AForm 1094-C (2021)DO NOT FILEMay 24, 2021 draft AS OF120218 Form 1094-C (2021)Page 2 Part IIIALE Member Information Monthly(a) Minimum Essential Coverage Offer Indicator YesNo(b) Section 4980H Full-Time Employee Count for ALE Member(c) Total Employee Count for ALE Member(d) Aggregated Group Indicator (e) Reserved 23 All 12 Months24 Jan25 Feb26 Mar27 Apr28 May29 June30 July31 Aug32 Sept33 Oct34 Nov35 DecForm 1094-C (2021)DO NOT FILEMay 24, 2021 draft AS OF120316 Form 1094-C (2021)

8 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 (2021)