Fillable 1095 C Form PDF Details

The 1095-C Form is used to report an employee's health care coverage. The form is used to report whether the employee had minimum essential coverage for each month of the tax year. This form must be submitted with the employees' federal income tax return. The IRS has made the fillable 1095 C Form available on their website. The form can be filled out and printed out for submission with the employees' federal income tax return. Be sure to visit the IRS website for more information on how to complete and submit the 1095-C Form.

Here is some information that might be beneficial if you are trying to find out how much time it will take you to complete fillable 1095 c form and how many PDF pages it has.

Form NameFillable 1095 C Form
Form Length4 pages
Fillable fields150
Avg. time to fill out31 min 4 sec
Other names1095-C, SSN, fillable 1095c, OMB

Form Preview Example


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


DRAFT FORMS. Also, do not rely on draft 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 legislationJulyis passed, necessitating24,a change to a2014draft form. In addition, forms generally are subject to OMB approval before they can be officially released. Drafts of instructions and publications usually have at least some changesDObefore being officiallyNOTreleased. FILE

Early releases of draft forms and instructions are at Please note that drafts may remain on even after the final release is posted at, and thus may not be removed until there is a new draft for the subsequent revision. All information about all revisions of all forms, instructions, and publications is at

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Form 1095-C



Employer-Provided Health Insurance Offer and Coverage
























Department of the Treasury



Information about Form 1095-C and its separate instructions is at


Internal Revenue Service

















Applicable Large Employer Member (Employer)



Part I
























Name of employee


July 24, 2014








2 Social security number (SSN)


7 Name of employer





8 Employer identification number (EIN)


Street address (including apartment no.)





9 Street address (including room or suite no.)



10 Contact telephone number












City or town


5 State or province

6 Country and ZIP or foreign postal code

11 City or town


12 State or province


13 Country and ZIP or foreign postal code



























Part II










Employee Offer and Coverage






























All 12 Months













14Offer of Coverage (enter required code)

15Employee Share of Lowest Cost Monthly Premium, for Self-Only

Minimum Value















16Applicable Section 4980H Safe Harbor (enter code, if applicable)

Part III

Covered Individuals

If Employer provided self-insured coverage, check the box and enter the information for each covered individual.

(a) Name of covered individual(s)

(b) SSN

(c) DOB (If SSN is

(d) Covered





(e) Months of Coverage













not available)

all 12 months





May June July

Aug Sept Oct























For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 60705M

Form 1095-C (2014)

Indicator Codes for Employee Offer and Coverage – Form 1095-C Part II, Line 14 Code Series #1, Offer of Coverage

1A. QualifiedDRAFTOffer: Minimum Essential Coverage providingASMinimum ValueOFoffered to full-time employee with employee contribution for self-only coverage equal to or less than 9.5% mainland single federal poverty line and Minimum Essential Coverage offered to spouse and dependent(s).

1B. MinimumJulyEssential Coverage providing24,Minimum Value2014offered to employee only.

1C. Minimum Essential Coverage providing Minimum Value offered to employee and at least Minimum Essential Coverage offered to dependent(s) (not spouse).

1D. MinimumDOEssential CoverageNOTproviding Minimum Value offeredFILEto employee and at least Minimum Essential Coverage offered to spouse (not dependent(s)).

1E. Minimum Essential Coverage providing Minimum Value offered to employee and at least Minimum Essential Coverage offered to dependent(s) and spouse.

1F. Minimum Essential Coverage not providing Minimum Value offered to employee, or employee and spouse or dependent(s), or employee, spouse and dependents.

1G. Offer of coverage to employee who was not a full-time employee for any month of the calendar year and who enrolled in self-insured coverage for one or more months of the calendar year.

1H. No offer of coverage (employee not offered any health coverage or employee offered coverage not providing Minimum Essential Coverage).

1I. Qualified Offer Transition Relief 2015: Employee (and spouse or dependents) received no offer of coverage, or received an offer of coverage that is not a Qualified Offer, or received a Qualified Offer for less than all 12 Months.

Code Series 2 Section 4980H Safe Harbor Codes and Other Relief for Employers - Form 1095- C Part II, Line 16

2A. Employee not employed during the month.

2B. Employee not a full-time employee.

2C. Employee enrolled in coverage offered.

2D. Employee in a section 4980H(b) limited non assessment period.

2E. Multiemployer interim rule relief.

2F. Section 4980H affordability Form W-2 safe harbor.


2G. Section 4980H affordability federal poverty line safe harbor.

2H. Section 4980H affordability rate of pay safe harbor.

2I. NonDRAFT-calendar year transition relief applies to thisASemployee. OF

July 24, 2014



How to Edit Fillable 1095 C Form Online for Free

This PDF editor was developed to be as easy as possible. When you stick to the following actions, the procedure for preparing the 2014 file will be convenient.

Step 1: First of all, select the orange "Get form now" button.

Step 2: Now you are on the document editing page. You can edit, add content, highlight particular words or phrases, place crosses or checks, and put images.

If you want to fill in the template, type in the details the application will request you to for each of the appropriate areas:

entering details in SSN step 1

Please fill out the For Paperwork Reduction Act, Cat, and Form 1095-C (2014) field with the necessary data.

SSN For Paperwork Reduction Act, Cat, and Form 1095-C (2014) fields to fill out

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