Form 1094-C

Information Reporting by Applicable Large Employers on Health Insurance Coverage Offered Under Employer-Sponsored Plans

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2251 can be found here:

Documents and Forms

Document Name Document Type
Form Form 1094-C Form 1094-C Form
i1094-c_and_1095_c--2017-00-00.pdf www.IRS.gov Instruction
Form 1094-C Transmittal of Employer-Provided Health Insurance Offer f1094-c--2017-00-00.pdf www.IRS.gov Form
Notice 2011-36.pdf Notice 2011-36 IC Document
Notice 2011-73.pdf Notice 2011-73 IC Document
Notice 2012-17.pdf Notice 2012-17 IC Document
Notice 2012-58.pdf Notice 2012-58 IC Document
REG-136630-12 NPRM.pdf REG-138006-12 IC Document

Information Collection (IC) Details

IC Title:	Form 1094-C	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 26 CFR 301.6011-8 26 CFR 301.6056-2 26 CFR 301.6056-1

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Form 1094-C	Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns	f1094-c--2017-00-00.pdf	www.IRS.gov	Yes	Yes	Fillable Fileable
Instruction			i1094-c_and_1095_c--2017-00-00.pdf	www.IRS.gov	Yes	Yes	Fillable Printable

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title: IRS 24.030- Individual Master File; IRS 24.046-Customer Account Data Engine Business Master File	FR Citation: 80 FR 54064

Number of Respondents: 400,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	400,000	385,000	15,000
Annual IC Time Burden (Hours)	1,600,000	1,540,000	60,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.