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1094-C
Transmittal of Employer-Provided Health Insurance Offer and
Coverage Information Returns
Form
Department of the Treasury
Internal Revenue Service
Part I
OMB No. 1545-2251
CORRECTED
2023
Go to www.irs.gov/Form1094C for instructions and the latest information.
Applicable Large Employer Member (ALE Member)
1 Name of ALE Member (Employer)
2 Employer identification number (EIN)
3 Street address (including room or suite no.)
4 City or town
5 State or province
6 Country and ZIP or foreign postal code
7 Name of person to contact
8 Contact telephone number
9 Name of Designated Government Entity (only if applicable)
10 Employer identification number (EIN)
11 Street address (including room or suite no.)
For Official Use Only
12 City or town
13 State or province
14 Country and ZIP or foreign postal code
15 Name of person to contact
17 Reserved .
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18 Total number of Forms 1095-C submitted with this transmittal
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19 Is this the authoritative transmittal for this ALE Member? If “Yes,” check the box and continue. If “No,” see instructions
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Part II
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16 Contact telephone number
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ALE Member Information
20 Total number of Forms 1095-C filed by and/or on behalf of ALE Member .
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21 Is ALE Member a member of an Aggregated ALE Group?
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Yes
No
If “No,” do not complete Part IV.
22 Certifications of Eligibility (select all that apply):
A. Qualifying Offer Method
B. Reserved
C. Reserved
D. 98% Offer Method
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.
Signature
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Date
Title
Cat. No. 61571A
Form 1094-C (2023)
120218
Page 2
Form 1094-C (2023)
Part III
ALE Member Information—Monthly
(a) Minimum Essential Coverage
Offer Indicator
Yes
23
No
(b) Section 4980H Full-Time
Employee Count for ALE Member
(c) Total Employee Count
for ALE Member
(d) Aggregated
Group Indicator
(e) Reserved
All 12 Months
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Jan
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Feb
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Apr
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May
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June
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July
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Sept
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Oct
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Nov
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Dec
Form 1094-C (2023)
120316
Page 3
Form 1094-C (2023)
Part IV
Other ALE Members of Aggregated ALE Group
Enter the names and EINs of Other ALE Members of the Aggregated ALE Group (who were members at any time during the calendar year).
Name
EIN
Name
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EIN
Form 1094-C (2023)
File Type | application/pdf |
File Title | 2023 Form 1094-C |
Subject | Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns |
Author | SE:W:CAR:MP |
File Modified | 2023-10-05 |
File Created | 2023-10-05 |