Wiki source code of IRS FORM 1095-B
Version 1.3 by steveny on 2023/05/04 15:11
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| author | version | line-number | content |
|---|---|---|---|
| 1 | == FORM 1095-B == | ||
| 2 | |||
| 3 | ===== [[image:/xwiki/bin/get/Windows/U.S./Affordable%20Care%20Act%20(ACA)%20%C2%BB/IRL%20Forms/IRS%20FORM%201095-B/?sheet=CKEditor.ResourceDispatcher&outputSyntax=plain&language=en&type=attach&typed=true&reference=1.png]]//Click on the individual boxes below for specific IRS Instructions | ||
| 4 | [[image:attach:1.png]]// ===== | ||
| 5 | |||
| 6 | |||
| 7 | |**Part I: Responsible Individual** | ||
| 8 | |((( | ||
| 9 | |[[Line 1, Name of Responsible Individual>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e619]] | ||
| 10 | |[[Line 2, Social Security Number of Responsible Individual>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e630]] | ||
| 11 | |[[Line 3, Birthdate (MM/DD/YYYY) of Responsible Individual if SSN is blank.>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e638]] | ||
| 12 | |||
| 13 | |[[Lines 4-7, Complete Mailing Address of the Responsible Individual>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e643]] | ||
| 14 | |[[Line 8, Letter Code of Origin of Policy (Policy Origin Code)>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e648]] | ||
| 15 | |[[Line 9, SHOP Identifier (Leave blank for 2015 filing)>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e677]] | ||
| 16 | ))) | ||
| 17 | |||
| 18 | |**Part II: Employer-Sponsored Coverage** | ||
| 19 | |[[Lines 10-15, Name, EIN, and Complete Mailing Address for the Employer Sponsoring the Coverage>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e693]] | ||
| 20 | |||
| 21 | |**Part III: Issuer or Other Coverage Provider** | ||
| 22 | |[[Lines 16-22, Name, EIN, and Complete Mailing Address of Issuer/ Other Coverage>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e704]] | ||
| 23 | |||
| 24 | |**Part IV: Covered Individuals** | ||
| 25 | |[[Column (a), Covered Individual's Name>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e712]] | ||
| 26 | |[[Column (b), Covered Individual's Social Security Number (SSN)>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e717]] | ||
| 27 | |[[Column (c), Covered Individual's Birthdate (MM/DD/YYY) if Social Security Number (SSN) is not available>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e725]] | ||
| 28 | |[[Column (d), Covered all 12 months>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e730]] | ||
| 29 | |[[Column (e), Months of Coverage>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e738]] | ||
| 30 | |||
| 31 | ===== ===== | ||
| 32 | |||
| 33 | [[image:/xwiki/bin/get/Windows/U.S./Affordable%20Care%20Act%20(ACA)%20%C2%BB/IRL%20Forms/IRS%20FORM%201095-B/?sheet=CKEditor.ResourceDispatcher&outputSyntax=plain&language=en&type=attach&typed=true&reference=2.png]]//[[image:attach:2.png]]// | ||
| 34 | |||
| 35 | |||
| 36 | |**Part IV: Covered Individuals (Continuation)** | ||
| 37 | |[[Column (a), Name of each Covered Individual>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e712]] | ||
| 38 | |[[Column (b), Social Security Number (SSN) of each Covered Individual>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e717]] | ||
| 39 | |[[Column (c), Birthdate (MM/DD/YYY) of each Covered Individual if SSN is not available>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e725]] | ||
| 40 | |[[Column (d), Individual Covered for 12 months>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e730]] | ||
| 41 | |[[Column (e), Coverage each month if individual wasn't covered for all 12 months>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e738]] | ||
| 42 | |||
| 43 | ===== ===== | ||
| 44 | |||
| 45 |