Form 1094-B Transmittal of Health Coverage Information Returns

110116
Form

1094-B

Department of the Treasury
Internal Revenue Service

OMB No. 1545-2252

Transmittal of Health Coverage Information Returns
▶ Go

2021

to www.irs.gov/Form1094B for instructions and the latest information.

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

7 State or province

8 Country and ZIP or foreign postal code

For Official Use Only

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

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

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Signature

Title

Cat. No. 61570P

Date
Form 1094-B (2021)