Federal Free Printable 2016 Form 1095-C for 2017 Federal Employer Provided Health Insurance Offer and Coverage

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Employer Provided Health Insurance Offer and Coverage
2016 Form 1095-C

600117 1095-C Form Department of the Treasury Internal Revenue Service Part I ▶ Information ▶ Do not attach to your tax return. Keep for your records. about Form 1095-C and its separate instructions is at www.irs.gov/form1095c Employee 2 Social security number (SSN) 3 Street address (including apartment no.) Part II 5 State or province All 12 Months $ CORRECTED Jan $ 8 Employer identification number (EIN) 9 Street address (including room or suite no.) 10 Contact telephone number 12 State or province 13 Country and ZIP or foreign postal code Plan Start Month (Enter 2-digit number): Feb $ 2016 7 Name of employer 6 Country and ZIP or foreign postal code 11 City or town Employee Offer of Coverage 14 Offer of Coverage (enter required code) 15 Employee Required Contribution (see instructions) OMB No. 1545-2251 Applicable Large Employer Member (Employer) 1 Name of employee 4 City or town VOID Employer-Provided Health Insurance Offer and Coverage Mar $ Apr $ May $ June $ July $ Aug Sept $ Oct $ $ Nov $ Dec $ 16 Section 4980H Safe Harbor and Other Relief (enter code, if applicable) Part III Covered Individuals If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee. (a) Name of covered individual(s) (b) SSN or other TIN (c) DOB (If SSN or other TIN is not available) (d) Covered all 12 months (e) Months of Coverage Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 17 18 19 20 21 22 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60705M Form 1095-C (2016) 600216 Page 2 Form 1095-C (2016) Instructions for Recipient Part II. Employer Offer of Coverage, Lines 14–16 You are receiving this Form 1095-C because your employer is an Applicable Large Employer subject to the employer shared responsibility provision in the Affordable Care Act. This Form 1095-C includes information about the health insurance coverage offered to you by your employer. Form 1095-C, Part II, includes information about the coverage, if any, your employer offered to you and your spouse and dependent(s). If you purchased health insurance coverage through the Health Insurance Marketplace and wish to claim the premium tax credit, this information will assist you in determining whether you are eligible. For more information about the premium tax credit, see Pub. 974, Premium Tax Credit (PTC). You may receive multiple Forms 1095-C if you had multiple employers during the year that were Applicable Large Employers (for example, you left employment with one Applicable Large Employer and began a new position of employment with another Applicable Large Employer). In that situation, each Form 1095-C would have information only about the health insurance coverage offered to you by the employer identified on the form. If your employer is not an Applicable Large Employer it is not required to furnish you a Form 1095-C providing information about the health coverage it offered. In addition, if you, or any other individual who is offered health coverage because of their relationship to you (referred to here as family members), enrolled in your employer's health plan and that plan is a type of plan referred to as a "self-insured" plan, Form 1095-C, Part III provides information to assist you in completing your income tax return by showing you or those family members had qualifying health coverage (referred to as "minimum essential coverage") for some or all months during the year. If your employer provided you or a family member health coverage through an insured health plan or in another manner, the issuer of the insurance or the sponsor of the plan providing the coverage will furnish you information about the coverage separately on Form 1095-B, Health Coverage. Similarly, if you or a family member obtained minimum essential coverage from another source, such as a government-sponsored program, an individual market plan, or miscellaneous coverage designated by the Department of Health and Human Services, the provider of that coverage will furnish you information about that coverage on Form 1095-B. If you or a family member enrolled in a qualified health plan through a Health Insurance Marketplace, the Health Insurance Marketplace will report information about that coverage on Form 1095-A, Health Insurance Marketplace Statement. 1H. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum essential coverage). TIP Employers are required to furnish Form 1095-C only to the employee. As the recipient of this Form 1095-C, you should provide a copy to any family members covered under a self-insured employer-sponsored plan listed in Part III if they request it for their records. Part I. Employee Lines 1–6. Part I, lines 1–6, reports information about you, the employee. Line 2. This is your social security number (SSN). For your protection, this form may show only the last four digits of your SSN. However, the employer is required to report your complete SSN to the IRS. ! ▲ If you do not provide your SSN and the SSNs of all covered individuals to the plan administrator, the IRS may not be able to match the Form 1095-C to determine that you and the other covered individuals have complied with the individual shared responsibility CAUTION provision. For covered individuals other than the employee listed in Part I, a Taxpayer Identification Number (TIN) may be provided instead of an SSN. See Part III. Part I. Applicable Large Employer Member (Employer) Lines 7–13. Part I, lines 7–13, reports information about your employer. Line 10. This line includes a telephone number for the person whom you may call if you have questions about the information reported on the form or to report errors in the information on the form and ask that they be corrected. Line 14. The codes listed below for line 14 describe the coverage that your employer offered to you and your spouse and dependent(s), if any. (If you received an offer of coverage through a multiemployer plan due to your membership in a union, that offer may not be shown on line 14.) The information on line 14 relates to eligibility for coverage subsidized by the premium tax credit for you, your spouse, and dependent(s). For more information about the premium tax credit, see Pub. 974. 1A. Minimum essential coverage providing minimum value offered to you with an employee required contribution for self-only coverage equal to or less than 9.5% (as adjusted) of the 48 contiguous states single federal poverty line and minimum essential coverage offered to your spouse and dependent(s) (referred to here as a Qualifying Offer). This code may be used to report for specific months for which a Qualifying Offer was made, even if you did not receive a Qualifying Offer for all 12 months of the calendar year. For information on the adjustment of the 9.5%, see IRS.gov. 1B. Minimum essential coverage providing minimum value offered to you and minimum essential coverage NOT offered to your spouse or dependent(s). 1C. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your dependent(s) but NOT your spouse. 1D. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your spouse but NOT your dependent(s). 1E. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your dependent(s) and spouse. 1F. Minimum essential coverage NOT providing minimum value offered to you, or you and your spouse or dependent(s), or you, your spouse, and dependent(s). 1G. You were NOT a full-time employee for any month of the calendar year but were enrolled in selfinsured employer-sponsored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box or in the separate monthly boxes for all 12 calendar months on line 14. 1I. Reserved. 1J. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered to your spouse; and minimum essential coverage NOT offered to your dependent(s). 1K. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered to your spouse; and minimum essential coverage offered to your dependent(s). Line 15. This line reports the employee required contribution, which is the monthly cost to you for the lowest-cost self-only minimum essential coverage providing minimum value that your employer offered you. The amount reported on line 15 may not be the amount you paid for coverage if, for example, you chose to enroll in more expensive coverage such as family coverage. Line 15 will show an amount only if code 1B, 1C, 1D, 1E, 1J, or 1K is entered on line 14. If you were offered coverage but there is no cost to you for the coverage, this line will report a “0.00” for the amount. For more information, including on how your eligibility for other healthcare arrangements might affect the amount reported on line 15, see IRS.gov. Line 16. This code provides the IRS information to administer the employer shared responsibility provisions. Other than a code 2C which reflects your enrollment in your employer's coverage, none of this information affects your eligibility for the premium tax credit. For more information about the employer shared responsibility provisions, see IRS.gov. Part III. Covered Individuals, Lines 17–22 Part III reports the name, SSN (or TIN for covered individuals other than the employee listed in Part I), and coverage information about each individual (including any full-time employee and non-full-time employee, and any employee's family members) covered under the employer's health plan, if the plan is "self-insured." A date of birth will be entered in column (c) only if an SSN (or TIN for covered individuals other than the employee listed in Part I) is not 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 6 covered individuals, see the additional covered individuals on Part III, Continuation Sheet(s). 600317 Page 3 Form 1095-C (2016) Name of employee Part III Social security number (SSN) 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 Sept Oct Nov Dec 23 24 25 26 27 28 29 30 31 32 33 34 Form 1095-C (2016)
Extracted from PDF file 2016-federal-form-1095-c.pdf, last modified September 2016

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

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

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Form 941 Employer's Quarterly Federal Tax Return
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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-C 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-C

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


2016 Form 1095-C

2016 Form 1095-C

Employer Provided Health Insurance Offer and Coverage 2015 Form 1095-C

2015 Form 1095-C


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