Form 1094 B PDF Details

Form 1094 B is used to report the healthcare coverage information of individuals to the IRS. This form is used to report whether an individual had minimum essential coverage for each month of the year. The form must be filed by February 28th of the year following the calendar year being reported. If you are a taxpayer who needs to file Form 1094 B, you will need to gather some information first. You will need information about each individual's healthcare coverage for the year, including information about any exemptions or waivers that were claimed. Furthermore, you will need the Employer Identification Number (EIN) of any employer who sponsored minimum essential coverage for one or more employees during the year. Once you have all this information collected, you can begin filling out Form 1094 B. Be sure to double-check your work before submitting it – after all, accuracy is key when reporting healthcare coverage data!

QuestionAnswer
Form NameForm 1094 B
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescity or ... - IRS tax forms, street address, PAYERS name

Form Preview Example

110116

Form 1094-B

 

Transmittal of Health Coverage Information Returns

 

 

 

 

 

 

 

 

 

 

 

OMB No. 1545-2252

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2021

 

 

 

 

Department of the Treasury

 

▶ Go to WWW.IRS.GOV/FORM1094B for instructions and the latest information.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Internal Revenue Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

Filer's name

 

 

2 Employer identification number (EIN)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

Name of person to contact

 

 

4 Contact telephone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

Street address (including room or suite no.)

 

6 City or town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Official Use Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

State or province

 

8 Country and ZIP or foreign postal code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9 Total number of Forms 1095-B submitted with this transmittal . . . . . . . . . . . . . . ▶

Under 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.

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Signature

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Title

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Date

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 61570P

Form 1094-B (2021)

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PAYERS name completion process clarified (portion 1)

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