IRS FORM 1095-C

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== FORM 1095-C ==

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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: Employee Applicable Large Employer Member (ALE Member/Employer)**

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|(((

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|**Employee**

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|[[Line 1, Employee's Name>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1069]]

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|[[Line 2, Employee's Social Security Number (including dashes)>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1074]]

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|[[Lines 3-6, Employee's Complete Address>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1079]]

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|**Employer (Should match information on 1094-C)**

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|[[Line 7, Employer's Name>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1087]]

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|[[Line 8, Employer's EIN>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1092]]

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|[[Lines 9 and 11-13, Employer's Complete Address>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1106]]

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|[[Line 10, Contact Person's Telephone Number>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1111]]

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)))

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|**Part II: Employee Offer and Coverage**

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|[[Employee Offer and Coverage - Plan Start Month>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1119]]

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|[[Line 14, Offer of Coverage (Code)>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1127]]

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|[[Line 15, Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1290]]

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|[[Line 16, Applicable Section 4980H safe Harbor (Code, if applicable)>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1319]]

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|**Part III: Covered Individuals**

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|(((

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[[Part III Lines 17-22, Covered Individuals>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1434]]

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)))

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[[image:attach:2.png]]

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|**Part III: Covered Individuals**

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|[[Column (a), Covered Individual's Name>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1492]]

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|[[Column (b), Covered Individual's Social Security Number (SSN)>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1497]]

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|[[Column (c), Covered Individual's Birthdate (MM/DD/YYY) if Social Security Number (SSN) is not available>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1502]]

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|[[Column (d), Covered all 12 months>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1507]]

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|[[Column (e), Months of Coverage>>url:https://www.aatrix.com/aca/supported-forms/1095-1094-c-instructions#d0e1515]]

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