Federal Free Printable 2016 Form 1095-B for 2017 Federal Health Coverage

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Health Coverage
2016 Form 1095-B

560116 Form 1095-B Department of the Treasury Internal Revenue Service Part I 1 Do not attach to your tax return. Keep for your records. Information about Form 1095-B and its separate instructions is at www.irs.gov/form1095b. 5 City or town 8 Enter letter identifying Origin of the Health Coverage (see instructions for codes): . . 3 Date of birth (If SSN or other TIN is not available) 6 State or province 7 9 Reserved ▶ 13 City or town 11 Employer identification number (EIN) 14 State or province 15 Country and ZIP or foreign postal code 17 Employer identification number (EIN) 18 Contact telephone number 21 State or province 22 Country and ZIP or foreign postal code Issuer or Other Coverage Provider (see instructions) Name 19 Street address (including room or suite no.) Part IV Country and ZIP or foreign postal code Information about Certain Employer-Sponsored Coverage (see instructions) 12 Street address (including room or suite no.) 16 . 2 Social security number (SSN or other TIN) Employer name Part III 2016 Responsible Individual Name of responsible individual Part II OMB No. 1545-2252 CORRECTED ▶ ▶ 4 Street address (including apartment no.) 10 VOID Health Coverage 20 City or town Covered Individuals (Enter the information for each covered individual.) (a) Name of covered individual(s) (b) SSN or other TIN (c) DOB (If SSN or other (d) Covered TIN is not available) all 12 months (e) Months of coverage Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 23 24 25 26 27 28 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60704B Form 1095-B (2016) 560216 Page 2 Form 1095-B (2016) Instructions for Recipient This Form 1095-B provides information needed to report on your income tax return that you, your spouse (if you file a joint return), and individuals you claim as dependents had qualifying health coverage (referred to as “minimum essential coverage”) for some or all months during the year. Individuals who don't have minimum essential coverage and don't qualify for an exemption from this requirement may be liable for the individual shared responsibility payment. Minimum essential coverage includes government-sponsored programs, eligible employer-sponsored plans, individual market plans, and other coverage the Department of Health and Human Services designates as minimum essential coverage. For more information on the requirement to have minimum essential coverage and what is minimum essential coverage, see www.irs.gov/Affordable-Care-Act/Individuals-and-Families/IndividualShared-Responsibility-Provision. Providers of minimum essential coverage are required to furnish only one Form 1095-B for all individuals whose coverage is reported on that form. As the recipient of this Form 1095-B, you should provide a copy to other individuals covered under the policy if they request it for their records. TIP Part I. Responsible Individual, lines 1–9. Part I reports information about you and the coverage. Lines 2 and 3. Line 2 reports your social security number (SSN) or other taxpayer identification number (TIN), if applicable. For your protection, this form may show only the last four digits. However, the coverage provider is required to report your complete SSN or other TIN, if applicable, to the IRS. Your date of birth will be entered on line 3 only if line 2 is blank. ! ▲ If you don't provide your SSN or other TIN and the SSNs or other TINs of all covered individuals to the sponsor of the coverage, the IRS may not be able to match the Form 1095-B with the individuals to CAUTION determine that they have complied with the individual shared responsibility provision. Line 8. This is the code for the type of coverage in which you or other covered individuals were enrolled. Only one letter will be entered on this line. A. Small Business Health Options Program (SHOP) B. Employer-sponsored coverage C. Government-sponsored program D. Individual market insurance E . Multiemployer plan F . Other designated minimum essential coverage If you or another family member received health insurance coverage through a Health Insurance Marketplace (also known as an Exchange), that coverage will generally be reported on a Form 1095-A rather than a Form 1095-B. If you or another family member received employer-sponsored coverage, that coverage may be reported on a Form 1095-C (Part III) rather than a Form 1095-B. For more information, see https://www.irs.gov/Affordable-Care-Act/Questions-and-Answers-aboutHealth-Care-Information-Forms-for-Individuals. TIP Line 9. Reserved. Part II. Information about Certain Employer-Sponsored Coverage, lines 10–15. If you had employer-sponsored health coverage, this part may provide information about the employer sponsoring the coverage. This part may show only the last four digits of the employer's EIN. This part may also be left blank, even if you had employer-sponsored health coverage. If this part is blank, you do not need to fill in the information or return it to your employer or other coverage provider. Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports information about the coverage provider (insurance company, employer providing self-insured coverage, government agency sponsoring coverage under a government program such as Medicaid or Medicare, or other coverage sponsor). Line 18 reports a telephone number for the coverage provider that you can call if you have questions about the information reported on the form. Part IV. Covered Individuals, lines 23–28. This part reports the name, SSN or other TIN, and coverage information for each covered individual. A date of birth will be entered in column (c) only if the SSN or other TIN isn't entered in column (b). Column (d) will be checked if the individual was covered for at least one day in every month of the year. For individuals who were covered for some but not all months, information will be entered in column (e) indicating the months for which these individuals were covered. If there are more than six covered individuals, see Part IV, Continuation Sheet(s), for information about the additional covered individuals. 560317 Page 3 Form 1095-B (2016) Name of responsible individual Part IV Social security number (SSN or other TIN) Date of birth (If SSN or other TIN is not available) Covered Individuals — Continuation Sheet (a) Name of covered individual(s) (b) SSN or other TIN (c) DOB (If SSN or other (d) Covered TIN is not available) all 12 months (e) Months of coverage Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 29 30 31 32 33 34 35 36 37 38 39 40 Form 1095-B (2016)
Extracted from PDF file 2016-federal-form-1095-b.pdf, last modified September 2016

More about the Federal Form 1095-B Corporate Income Tax TY 2016

We last updated the Health Coverage in May 2017, so this is the latest version of Form 1095-B, fully updated for tax year 2016. You can download or print current or past-year PDFs of Form 1095-B directly from TaxFormFinder. You can print other Federal tax forms here.


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Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 1095-B from the Internal Revenue Service in May 2017.

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About the Corporate Income Tax

The IRS and most states require corporations to file an income tax return, with the exact filing requirements depending on the type of company.

Sole proprietorships or disregarded entities like LLCs are filed on Schedule C (or the state equivalent) of the owner's personal income tax return, flow-through entities like S Corporations or Partnerships are generally required to file an informational return equivilent to the IRS Form 1120S or Form 1065, and full corporations must file the equivalent of federal Form 1120 (and, unlike flow-through corporations, are often subject to a corporate tax liability).

Additional forms are available for a wide variety of specific entities and transactions including fiduciaries, nonprofits, and companies involved in other specific types of business.

Historical Past-Year Versions of Federal Form 1095-B

We have a total of two past-year versions of Form 1095-B in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2016 Form 1095-B

2016 Form 1095-B

Health Coverage 2015 Form 1095-B

2015 Form 1095-B


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