IRS FORM 1095-B

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== FORM 1095-B ==

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===== //Click on the individual boxes below for specific IRS Instructions

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[[image:attach:1.png]]// =====

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|**Part I: Responsible Individual**

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|(((

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|[[Line 1, Name of Responsible Individual>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e619]]

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|[[Line 2, Social Security Number of Responsible Individual>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e630]]

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|[[Line 3, Birthdate (MM/DD/YYYY) of Responsible Individual if SSN is blank.>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e638]]

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|[[Lines 4-7, Complete Mailing Address of the Responsible Individual>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e643]]

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|[[Line 8, Letter Code of Origin of Policy (Policy Origin Code)>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e648]]

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|[[Line 9, SHOP Identifier (Leave blank for 2015 filing)>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e677]]

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)))

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|**Part II: Employer-Sponsored Coverage**

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|[[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]]

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|**Part III: Issuer or Other Coverage Provider**

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|[[Lines 16-22, Name, EIN, and Complete Mailing Address of Issuer/ Other Coverage>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e704]]

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|**Part IV: Covered Individuals**

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|[[Column (a), Covered Individual's Name>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e712]]

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|[[Column (b), Covered Individual's Social Security Number (SSN)>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e717]]

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|[[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]]

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|[[Column (d), Covered all 12 months>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e730]]

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|[[Column (e), Months of Coverage>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e738]]

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|**Part IV: Covered Individuals (Continuation)**

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|[[Column (a), Name of each Covered Individual>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e712]]

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|[[Column (b), Social Security Number (SSN) of each Covered Individual>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e717]]

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|[[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]]

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|[[Column (d), Individual Covered for 12 months>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e730]]

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|[[Column (e), Coverage each month if individual wasn't covered for all 12 months>>url:https://www.irs.gov/instructions/i109495b/ar01.html#d0e738]]

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