HEALTH & WELFARE PLAN LUNCH GROUP

HEALTH & WELFARE PLAN LUNCH GROUP October 1, 2015 ALSTON & BIRD LLP One Atlantic Center 1201 W. Peachtree Street Atlanta, GA 30309-3424 (404) 881-7885 E-mail: john.hickman@alston.com 2015 All Rights Reserved

INDEX 1. 6056 Reporting and Disclosure Rules: Practical Applications 2. Forms 1095-C Examples (#1 - #8)

Health & Welfare Benefits Monthly Update

6056 Reporting and Disclosure Rules Practical Applications Ashley Gillihan, Esq. ashley.gillihan@alston.com 2014, Alston & Bird, LLP

Welcome! John Hickman, Esq. Ashley Gillihan, Esq. 3

Agenda Understand the requirements that underlie the Forms Code Section 6055 Code Section 6056 Answer the following questions with respect to each Code Section: Why Who What How When Walk through some examples

6055 Why? To give IRS and Taxpayers information necessary to administer the individual mandate!!!!!

6055 Who? Coverage Provider If plan is fully insured, carrier is responsible for reporting If plan is self-insured, plan sponsor is responsible for reporting Each employer whose employees/former employees participate in the plan is responsible for reporting» Special reporting rule for members of controlled group that is not an ALE Each employer participating in a MEWA constitutes a separate and independent plan sponsor If plan is multi-employer plan, joint board of trustees, association, or committee who maintains the plan

6055 Who? Third Party may file on behalf of coverage provider BUT coverage provider remains liable What steps must third party take to file on behalf of a coverage provider? Special rule for governmental entities

6055 What? Identify all individuals covered under a plan providing minimum essential coverage at least one day of any month DURING THE CALENDAR YEAR Includes employees, retirees, dependents, independent contractors, qualified beneficiaries, alternate recipients covered pursuant to a QMCSO, non-employee board members 6724 Solicitation of Dependent s SSN (see Notice 2015-68) The 3 requests requirement» When the relationship begins» By December 31 of the year in which the relationship begins» By December 31 of the next year Use DOB if unable to receive the dependent s SSN

6055 What? Plan year not relevant; all 6055 reporting is done on a calendar year basis No description of coverage needed What is MEC? Any group health plan that provides other than excepted benefits Affordability not relevant Minimum value not relevant NOTE: No reporting for supplemental coverage Secondary to other MEC IF COVERAGE UNDER PLAN IS CONDITIONED ON ENROLLMENT IN OTHER MEC E.g. Major medical that is secondary to Medicare BUT ONLY IF ENROLLMENT IN MAJOR MEDICAL IS CONDITIONED ON ENROLLMENT IN MEDICARE Self insured, integrated coverage supplemental (e.g. HRA) to FULLY INSURED major medical of same plan sponsor

6055 How? Generally, coverage providers will use 1094/1095-B series to report MEC enrollments to IRS and responsible individuals HOWEVER, if plan is self funded and sponsored/maintained by applicable large employer member, then....... MUSTuse 1094/1095-C series to report any individual who was an employee in any month of the calendar year, and his/her dependents, who were covered under the self-insured MEC plan at least one day of any month in the calendar year May but not required to use C-Series to report individuals covered under self-insured MEC plan who were not employees at any time during the year If C-series not used for non-employee covered individuals, then use B-Series.

6055 How? Send to last known address of responsible individual Employee Former employee Parent Alternate recipient covered pursuant to QMCSO Other individual who enrolls themself and others Qualified beneficiary ex-spouse? First class mail Electronic if advance consent provided by responsible individual

6055 When? In the year following the calendar year being reported To IRS: March 31 if filing electronically February 28 if filing paper forms To Responsible Individual : January 31

6056 Why? So IRS can administer employer shared responsibility requirements So IRS and taxpayers can administer the premium tax credit/subsidy under Code Section 36B Although any employee can qualify for credit/subsidy, no reporting for credit/subsidy related reporting required for other than full-time employees

6056 Who? Each applicable large employer member Each member of the controlled group of corporations ( ALE member ) that constitute an applicable large employer is independently responsible for reporting Third Party may file on behalf of ALE member BUT ALE member remains liable»special rule for governmental entities (same rule as applicable under 6055)

6056 What? Identify all employees who were full-time employees (as defined by 4980H) at least one full month during the year Identify the coverage that was offered, if any, during all months in a year that the employee was a full-time employee for at least one month If coverage was not offered for an entire month, identify whether any exceptions to excise tax apply E.g. employee not employed during that month E.g. employee part time during the month E.g. employee in limited non-assessment period E.g. Month or employee is subject to transition relief If coverage offered during a month, indicate whether coverage was affordable or not in such month

6056 What? It doesn t matter for 6056 purposes whether coverage is fully-insured or self-insured, or even whether coverage is offered at all. If an employer is an ALE member, and the employer has at least one employee who qualified as a 4980H full-time employee, 6056 REPORTING IS REQUIRED!!!!!!

6056 How? Use 1094/1095-C series to report to IRS and full-time employees. Send to last known address of full-time employee First class mail Electronic if advance consent provided by responsible individual Relief for full-time employee reporting for: Full-time employees who received a Qualifying Offer for all 12 months Relief not applicable with respect to such full-time employees who actually enrolled in a self-insured plan Employers subject to Qualifying Offer Method Transition Relief (only for 2015) Relief for reporting to IRS and full-time employees under 98% offer method

6056 When? In the year following the calendar year being reported To IRS: March 31 if filing electronically February 28 if filing paper forms To full-time employee: January 31

Key Clarifications in Instructions Clarity on 6055 reporting by ALE members for individuals who are not employees at any time during calendar year but are enrolled in self-insured plan Reporting relief for full-time employees who receive a qualifying offer for all 12 months not available if actually enrolled in a self insured plan. Offer to spouse conditioned on reasonable objective restrictions still considered an offer even if spouse doesn t meet condition E.g. spouse is eligible to enroll only if not eligible for other employer coverage is reasonable objective restriction Clarification regarding supplemental coverage (e.g. HRAs) Codes for multi-employer transition relief Reporting for COBRA offers Special rule for COBRA to active employees (e.g. full-time to part-time or leave of absence) Special rule for COBRA to terminated employees (never treated as receiving an offer or being enrolled for 6056 purposes)

1095-C: Example #1 Bob is employed by ABC on April 15, 2015. Bob is hired into a full-time position. ABC s health plan imposes a 60 day waiting period on full-time employees. Thus, if Bob enrolls, his coverage will be effective June 15, 2015. Bob is offered the following coverage options from which to choose: Coverage under Option A, a HDHP health plan for which the employee contribution for self only coverage is 92.00 per month. The HDHP provides minimum value. Coverage for the spouse and dependent children (if any) is also offered. Coverage under Option B, a PPO for which the employee contribution for self only coverage is 150 per month. Coverage for the spouse and dependent children (if any ) is also offered. Bob does NOT enroll in the health plan.

1095-C: Example #2 Same facts as example #1 except for the following: Bob enrolls only himself in the plan. On November 15, 2015, Bob transfers to a parttime position. As a result his coverage is terminated and he is offered COBRA continuation coverage. The COBRA premium for self only is 450 per month. He does not elect COBRA.

1095-C: Example #3 Joe is employed by ABC on October 18, 2014. Joe is hired as a part-time employee. ABC offers coverage to part-time employees who average the requisite hours of service over the initial measurement period, which is 11 months in duration and begins on the first day of the month following the date of hire. Joe s initial measurement period began November 1, 2014 and ended September 30, 2015. Joe averages 30 hours of service per week during the initial measurement period ending September 30, 2015. Consequently, Joe qualifies as a full-time employee for each month of the stability period beginning December 1, 2015. Joe is only offered coverage under one option under the plan a PPO that provides minimum value for which the employee contribution for self only coverage is 90 per month. Coverage is also offered for the spouse and dependent children (if any). Joe enrolls himself and his spouse for the month of December 2015.

1095-C: Example #4 Starcy Clack is a full-time employee employed by Ash Lee Company. During annual enrollment for the 2015 plan year, Starcy was offered two different health plan coverage options, both of which offered coverage for Starcy s spouse and children, provided MV and charged a premium for self-only coverage that was less than 9.5% of FPL (i.e. this was a qualifying offer ). Starcy enrolls herself and her spouse. On November 15, 2015, Starcy terminates employment and her coverage ends. She is offered COBRA coverage. The premium for COBRA offered to her and her spouse is 1200 per month. She enrolls in the plan.

1095-C: Example #5 Joan Glickman Company sponsors a health plan that offers coverage beginning date of hire to all full-time employees. In addition, part-time employees may become eligible as of the first day of a stability period if they average 30 hours per week during the first 12 months of employment (i.e. initial measurement period) JGC occasionally needs temporary employees to fill in when full-time employees are sick. These temporary employees are employed at various times during the year and may work anywhere from 1-3 months. They are not eligible for coverage under the plan. Don Tyler is hired on February 15, 2015 as a temporary employee. He works full-time the remainder of February, all of March and all of April.

1095-C: Example #6 A&B is a party to a collective bargaining agreement with the Great Lawyers Associate Union (GLAU). Under the agreement, GLAU will offer minimum value coverage to each fulltime employee of ABC after 3 months of full-time work (seniority attainment date). The cost of employee only coverage is 10 per month. In addition to coverage for the employee, coverage is available for spouse and dependent children (if any). In exchange for offering coverage, A&B will begin making contributions in the first month of the employee s employment. Union employee is hired January 1, 2015. Union employee is hired as a fulltime employee expected to average 30 hours of service per week. GLAU makes a qualifying offer on April 1, 2015.

1095-C: Example #7 ABC sponsors a self-insured plan for a division of the company ( Division ) that operates on an April 1 through March 31 plan year ( Fiscal Year Plan ). Ray is a full-time employee of Division. Ray is not eligible for any of the calendar year plans sponsored by ABC and Ray satisfied the terms of eligibility in effect under the Plan on February 9, 2014. Ray is offered minimum value coverage for himself, spouse and dependent children (if any) that will be effective April 1, 2015 (if he enrolls). The premium for the lowest cost self only is 100 per month. ABC uses the W-2 safe harbor for affordability. In addition, ABC satisfies the 95% substantially all test in April 2015. Ray does not enroll.

1095-C: Example #8 Jody is a part-time employee of ABC. Jody does not qualify as a full-time employee at any time during 2015. ABC offers to part-time employees a self-insured MEC plan that is neither affordable nor provides minimum value. Jody enrolls himself and his spouse, Judy, in the plan. Coverage is effective for both April 15, 2015. Jody terminates employment on November 2, 2015 and does not elect COBRA. Consequently, coverage under the plan ends on November 2, 2015.

Question & Answer 28

Thank you! John Hickman, Esq. john.hickman@alston.com Ashley Gillihan, Esq. ashley.gillihan@alston.com 29

1095-C Form Department of the Treasury Internal Revenue Service Part I Information OMB No. 1545-2251 CORRECTED about Form 1095-C and its separate instructions is at www.irs.gov/form1095c Employee 600116 VOID Employer-Provided Health Insurance Offer and Coverage Applicable Large Employer Member (Employer) 1 Name of employee 2 Social security number (SSN) 2015 7 Name of employer 8 Employer identification number (EIN) 9 Street address (including room or suite no.) 10 Contact telephone number Example #1 3 Street address (including apartment no.) NOT INTENDED AS LEGAL OR TAX ADVICE/FOR INSTRUCTION ONLY 5 State or province 4 City or town 6 Country and ZIP or foreign postal code 11 City or town Coverage offer only for part of month Employee Offer and Coverage Part II can you use 1E instead? Plan Start Month (Enter 2-digit number): Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 1G 1A 1A 1A 1A 1A 1A 16 Applicable Section 4980H Safe Harbor (enter code, if applicable) 2A Covered Individuals Part III 13 Country and ZIP or foreign postal code All 12 Months 14 Offer of Coverage (enter required code) 15 Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage 12 State or province 2A 2A 2D 2D if using 1A, do you need to complete 16? 2D If Employer provided self-insured coverage, check the box and enter the information for each covered individual. (a) Name of covered individual(s) 17 18 (b) SSN Jody 111-11-3333 Judy 111-11-2222 (c) DOB (If SSN is not available) (d) Covered all 12 months (e) Months of Coverage Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 19 20 21 22 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60705M Form 1095-C (2015)

600215 Form 1095-C (2015) Page 2 Instructions for Recipient 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. 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 issuer 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 CAUTION responsibility provision. For covered individuals other than the employee listed in Part I, a Taxpayer Identification Number (TIN) may be provided instead of an SSN. 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. Part II. Employer Offer and Coverage, Lines 14 16 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 contribution for self-only coverage equal to or less than 9.5% 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. 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 self-insured employer-sponsored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box on line 14.. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum essential coverage). 1I. Your employer claimed "Qualifying Offer Transition Relief" for 2015 and for at least one month of the year you (and your spouse or dependent(s)) did not receive a Qualifying Offer. Note that your employer has also provided a contact number at which you may request further information about the health coverage, if any, you were offered (see line 10). Line 15. This line reports the employee share of the lowest-cost monthly premium for 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, or 1E is entered on line 14. If you were offered coverage but not required to contribute any amount towards the premium, this line will report a 0.00 for the amount. 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).

600316 Page 3 Form 1095-C (2015) Name of employee Part III Social security number (SSN) Covered Individuals Continuation Sheet (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not (d) Covered 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 (2015)

1095-C Form Department of the Treasury Internal Revenue Service Part I Information OMB No. 1545-2251 CORRECTED about Form 1095-C and its separate instructions is at www.irs.gov/form1095c Employee 600116 VOID Employer-Provided Health Insurance Offer and Coverage Applicable Large Employer Member (Employer) 1 Name of employee 2 Social security number (SSN) 2015 7 Name of employer 8 Employer identification number (EIN) 9 Street address (including room or suite no.) 10 Contact telephone number Example #2 3 Street address (including apartment no.) NOT INTENDED AS LEGAL OR TAX ADVICE/FOR INSTRUCTION ONLY 5 State or province 4 City or town Part II 15 Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage 12 State or province 13 Country and ZIP or foreign postal code Plan Start Month (Enter 2-digit number): Employee Offer and Coverage All 12 Months Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 1G 1A 1A 1A 1A 1B 1B 14 Offer of Coverage (enter required code) 16 Applicable Section 4980H Safe Harbor (enter code, if applicable) Part III 6 Country and ZIP or foreign postal code 11 City or town 2A Covered Individuals 2A 2A 2D 2D 2D 2C 2C 2C 450 2B 2C 450 2B If Employer provided self-insured coverage, check the box and enter the information for each covered individual. (a) Name of covered individual(s) 17 18 (b) SSN Bob 111-11-1112 Judy 111-11-2222 (c) DOB (If SSN is not available) (d) Covered all 12 months (e) Months of Coverage Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 19 20 21 22 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60705M Form 1095-C (2015)

600215 Form 1095-C (2015) Page 2 Instructions for Recipient 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. 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 issuer 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 CAUTION responsibility provision. For covered individuals other than the employee listed in Part I, a Taxpayer Identification Number (TIN) may be provided instead of an SSN. 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. Part II. Employer Offer and Coverage, Lines 14 16 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 contribution for self-only coverage equal to or less than 9.5% 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. 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 self-insured employer-sponsored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box on line 14.. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum essential coverage). 1I. Your employer claimed "Qualifying Offer Transition Relief" for 2015 and for at least one month of the year you (and your spouse or dependent(s)) did not receive a Qualifying Offer. Note that your employer has also provided a contact number at which you may request further information about the health coverage, if any, you were offered (see line 10). Line 15. This line reports the employee share of the lowest-cost monthly premium for 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, or 1E is entered on line 14. If you were offered coverage but not required to contribute any amount towards the premium, this line will report a 0.00 for the amount. 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).

600316 Page 3 Form 1095-C (2015) Name of employee Part III Social security number (SSN) Covered Individuals Continuation Sheet (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not (d) Covered 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 (2015)

1095-C Form Department of the Treasury Internal Revenue Service Part I Information OMB No. 1545-2251 CORRECTED about Form 1095-C and its separate instructions is at www.irs.gov/form1095c Employee 600116 VOID Employer-Provided Health Insurance Offer and Coverage Applicable Large Employer Member (Employer) 1 Name of employee 2 Social security number (SSN) 2015 7 Name of employer 8 Employer identification number (EIN) 9 Street address (including room or suite no.) 10 Contact telephone number Example #3 3 Street address (including apartment no.) NOT INTENDED AS LEGAL OR TAX ADVICE/FOR INSTRUCTION ONLY 5 State or province 4 City or town Part II 15 Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage 12 State or province 13 Country and ZIP or foreign postal code Plan Start Month (Enter 2-digit number): Employee Offer and Coverage All 12 Months Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 1G 1A 14 Offer of Coverage (enter required code) 16 Applicable Section 4980H Safe Harbor (enter code, if applicable) Part III 6 Country and ZIP or foreign postal code 11 City or town 2D Covered Individuals 2D 2D 2D 2D 2D 2D 2D 2D 2D 2D 2C If Employer provided self-insured coverage, check the box and enter the information for each covered individual. (a) Name of covered individual(s) 17 18 Joe Joe's Spouse (b) SSN (c) DOB (If SSN is not available) (d) Covered all 12 months (e) Months of Coverage Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 111-11-111 111-11-2222 4/19/1967 19 20 21 22 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60705M Form 1095-C (2015)

600215 Form 1095-C (2015) Page 2 Instructions for Recipient 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. 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 issuer 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 CAUTION responsibility provision. For covered individuals other than the employee listed in Part I, a Taxpayer Identification Number (TIN) may be provided instead of an SSN. 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. Part II. Employer Offer and Coverage, Lines 14 16 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 contribution for self-only coverage equal to or less than 9.5% 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. 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 self-insured employer-sponsored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box on line 14.. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum essential coverage). 1I. Your employer claimed "Qualifying Offer Transition Relief" for 2015 and for at least one month of the year you (and your spouse or dependent(s)) did not receive a Qualifying Offer. Note that your employer has also provided a contact number at which you may request further information about the health coverage, if any, you were offered (see line 10). Line 15. This line reports the employee share of the lowest-cost monthly premium for 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, or 1E is entered on line 14. If you were offered coverage but not required to contribute any amount towards the premium, this line will report a 0.00 for the amount. 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).

600316 Page 3 Form 1095-C (2015) Name of employee Part III Social security number (SSN) Covered Individuals Continuation Sheet (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not (d) Covered 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 (2015)

1095-C Form Department of the Treasury Internal Revenue Service Part I Information OMB No. 1545-2251 CORRECTED about Form 1095-C and its separate instructions is at www.irs.gov/form1095c Employee 600116 VOID Employer-Provided Health Insurance Offer and Coverage Applicable Large Employer Member (Employer) 1 Name of employee 2 Social security number (SSN) 2015 7 Name of employer 8 Employer identification number (EIN) 9 Street address (including room or suite no.) 10 Contact telephone number Example #4 3 Street address (including apartment no.) NOT INTENDED AS LEGAL OR TAX ADVICE/FOR INSTRUCTION ONLY 5 State or province 4 City or town 6 Country and ZIP or foreign postal code 11 City or town All 12 Months Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 1G 1A 1A 1A 1A 1A 1A 1A 1A 1A 1A 14 Offer of Coverage (enter required code) 15 Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage 16 Applicable Section 4980H Safe Harbor (enter code, if applicable) 2C Covered Individuals Part III 13 Country and ZIP or foreign postal code Plan Start Month (Enter 2-digit number): Employee Offer and Coverage Part II 12 State or province 2C 2C 2C 2C 2C 2C 2C 2C 2C 2B 2A If Employer provided self-insured coverage, check the box and enter the information for each covered individual. (a) Name of covered individual(s) 17 18 (b) SSN Starcy 111-11-3333 Spouse 111-11-2222 (c) DOB (If SSN is not available) (d) Covered all 12 months (e) Months of Coverage Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 19 20 21 22 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60705M Form 1095-C (2015)

600215 Form 1095-C (2015) Page 2 Instructions for Recipient 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. 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 issuer 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 CAUTION responsibility provision. For covered individuals other than the employee listed in Part I, a Taxpayer Identification Number (TIN) may be provided instead of an SSN. 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. Part II. Employer Offer and Coverage, Lines 14 16 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 contribution for self-only coverage equal to or less than 9.5% 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. 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 self-insured employer-sponsored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box on line 14.. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum essential coverage). 1I. Your employer claimed "Qualifying Offer Transition Relief" for 2015 and for at least one month of the year you (and your spouse or dependent(s)) did not receive a Qualifying Offer. Note that your employer has also provided a contact number at which you may request further information about the health coverage, if any, you were offered (see line 10). Line 15. This line reports the employee share of the lowest-cost monthly premium for 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, or 1E is entered on line 14. If you were offered coverage but not required to contribute any amount towards the premium, this line will report a 0.00 for the amount. 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).

600316 Page 3 Form 1095-C (2015) Name of employee Part III Social security number (SSN) Covered Individuals Continuation Sheet (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not (d) Covered 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 (2015)

full-time March and April but no code applies 1095-C Form Department of the Treasury Internal Revenue Service Part I Information OMB No. 1545-2251 CORRECTED about Form 1095-C and its separate instructions is at www.irs.gov/form1095c Employee 600116 VOID Employer-Provided Health Insurance Offer and Coverage Applicable Large Employer Member (Employer) 1 Name of employee 2 Social security number (SSN) 2015 7 Name of employer 8 Employer identification number (EIN) 9 Street address (including room or suite no.) 10 Contact telephone number Example #5 3 Street address (including apartment no.) NOT INTENDED AS LEGAL OR TAX ADVICE/FOR INSTRUCTION ONLY 5 State or province 4 City or town 6 Country and ZIP or foreign postal code 11 City or town All 12 Months 14 Offer of Coverage (enter required code) 15 Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 16 Applicable Section 4980H Safe Harbor (enter code, if applicable) 2A Covered Individuals Part III 13 Country and ZIP or foreign postal code Plan Start Month (Enter 2-digit number): Employee Offer and Coverage Part II 12 State or province 2D If Employer provided self-insured coverage, check the box and enter the information for each covered individual. (a) Name of covered individual(s) 17 18 (b) SSN Jody 111-11-3333 Judy 111-11-2222 (c) DOB (If SSN is not available) (d) Covered all 12 months (e) Months of Coverage Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 19 20 21 22 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60705M Form 1095-C (2015)

600215 Form 1095-C (2015) Page 2 Instructions for Recipient 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. 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 issuer 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 CAUTION responsibility provision. For covered individuals other than the employee listed in Part I, a Taxpayer Identification Number (TIN) may be provided instead of an SSN. 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. Part II. Employer Offer and Coverage, Lines 14 16 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 contribution for self-only coverage equal to or less than 9.5% 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. 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 self-insured employer-sponsored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box on line 14.. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum essential coverage). 1I. Your employer claimed "Qualifying Offer Transition Relief" for 2015 and for at least one month of the year you (and your spouse or dependent(s)) did not receive a Qualifying Offer. Note that your employer has also provided a contact number at which you may request further information about the health coverage, if any, you were offered (see line 10). Line 15. This line reports the employee share of the lowest-cost monthly premium for 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, or 1E is entered on line 14. If you were offered coverage but not required to contribute any amount towards the premium, this line will report a 0.00 for the amount. 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).

600316 Page 3 Form 1095-C (2015) Name of employee Part III Social security number (SSN) Covered Individuals Continuation Sheet (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not (d) Covered 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 (2015)

1095-C Form Department of the Treasury Internal Revenue Service Part I Information OMB No. 1545-2251 CORRECTED about Form 1095-C and its separate instructions is at www.irs.gov/form1095c Employee 600116 VOID Employer-Provided Health Insurance Offer and Coverage Applicable Large Employer Member (Employer) 1 Name of employee 2 Social security number (SSN) 2015 7 Name of employer 8 Employer identification number (EIN) 9 Street address (including room or suite no.) 10 Contact telephone number Example #6 3 Street address (including apartment no.) NOT INTENDED AS LEGAL OR TAX ADVICE/FOR INSTRUCTION ONLY 5 State or province 4 City or town 6 Country and ZIP or foreign postal code 11 City or town All 12 Months 14 Offer of Coverage (enter required code) 15 Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage Jan 13 Country and ZIP or foreign postal code Plan Start Month (Enter 2-digit number): Employee Offer and Coverage Part II 12 State or province Feb Mar Apr May June July Aug Sept Oct Nov Dec 16 Applicable Section 4980H Safe Harbor (enter code, if applicable) 2E Covered Individuals Part III If Employer provided self-insured coverage, check the box and enter the information for each covered individual. (a) Name of covered individual(s) 17 18 (b) SSN Jody 111-11-3333 Judy 111-11-2222 (c) DOB (If SSN is not available) (d) Covered all 12 months (e) Months of Coverage Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 19 20 21 22 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60705M Form 1095-C (2015)

600215 Form 1095-C (2015) Page 2 Instructions for Recipient 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. 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 issuer 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 CAUTION responsibility provision. For covered individuals other than the employee listed in Part I, a Taxpayer Identification Number (TIN) may be provided instead of an SSN. 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. Part II. Employer Offer and Coverage, Lines 14 16 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 contribution for self-only coverage equal to or less than 9.5% 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. 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 self-insured employer-sponsored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box on line 14.. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum essential coverage). 1I. Your employer claimed "Qualifying Offer Transition Relief" for 2015 and for at least one month of the year you (and your spouse or dependent(s)) did not receive a Qualifying Offer. Note that your employer has also provided a contact number at which you may request further information about the health coverage, if any, you were offered (see line 10). Line 15. This line reports the employee share of the lowest-cost monthly premium for 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, or 1E is entered on line 14. If you were offered coverage but not required to contribute any amount towards the premium, this line will report a 0.00 for the amount. 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).

600316 Page 3 Form 1095-C (2015) Name of employee Part III Social security number (SSN) Covered Individuals Continuation Sheet (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not (d) Covered 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 (2015)

1095-C Form Department of the Treasury Internal Revenue Service Part I Information OMB No. 1545-2251 CORRECTED about Form 1095-C and its separate instructions is at www.irs.gov/form1095c Employee 600116 VOID Employer-Provided Health Insurance Offer and Coverage Applicable Large Employer Member (Employer) 1 Name of employee 2 Social security number (SSN) 2015 7 Name of employer 8 Employer identification number (EIN) 9 Street address (including room or suite no.) 10 Contact telephone number Example #7 3 Street address (including apartment no.) NOT INTENDED AS LEGAL OR TAX ADVICE/FOR INSTRUCTION ONLY 5 State or province 4 City or town 6 Country and ZIP or foreign postal code 11 City or town All 12 Months Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 1G 1E 1E 1E 1E 1E 1E 1E 1E 1E 14 Offer of Coverage (enter required code) 15 Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage 16 Applicable Section 4980H Safe Harbor (enter code, if applicable) 2I Covered Individuals Part III 13 Country and ZIP or foreign postal code Plan Start Month (Enter 2-digit number): Employee Offer and Coverage Part II 12 State or province 2I 2I 100 2F 100 2F 100 2F 100 2F 100 2F 100 100 2F 2F 100 2F 100 2F If Employer provided self-insured coverage, check the box and enter the information for each covered individual. (a) Name of covered individual(s) 17 18 (b) SSN Jody 111-11-3333 Judy 111-11-2222 (c) DOB (If SSN is not available) (d) Covered all 12 months (e) Months of Coverage Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 19 20 21 22 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60705M Form 1095-C (2015)

600215 Form 1095-C (2015) Page 2 Instructions for Recipient 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. 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 issuer 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 CAUTION responsibility provision. For covered individuals other than the employee listed in Part I, a Taxpayer Identification Number (TIN) may be provided instead of an SSN. 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. Part II. Employer Offer and Coverage, Lines 14 16 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 contribution for self-only coverage equal to or less than 9.5% 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. 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 self-insured employer-sponsored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box on line 14.. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum essential coverage). 1I. Your employer claimed "Qualifying Offer Transition Relief" for 2015 and for at least one month of the year you (and your spouse or dependent(s)) did not receive a Qualifying Offer. Note that your employer has also provided a contact number at which you may request further information about the health coverage, if any, you were offered (see line 10). Line 15. This line reports the employee share of the lowest-cost monthly premium for 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, or 1E is entered on line 14. If you were offered coverage but not required to contribute any amount towards the premium, this line will report a 0.00 for the amount. 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).

600316 Page 3 Form 1095-C (2015) Name of employee Part III Social security number (SSN) Covered Individuals Continuation Sheet (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not (d) Covered 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 (2015)

1095-C Form Department of the Treasury Internal Revenue Service Part I Information OMB No. 1545-2251 CORRECTED about Form 1095-C and its separate instructions is at www.irs.gov/form1095c Employee 600116 VOID Employer-Provided Health Insurance Offer and Coverage Applicable Large Employer Member (Employer) 1 Name of employee 2 Social security number (SSN) 2015 7 Name of employer 8 Employer identification number (EIN) 9 Street address (including room or suite no.) 10 Contact telephone number Example #8 3 Street address (including apartment no.) NOT INTENDED AS LEGAL OR TAX ADVICE/FOR INSTRUCTION ONLY 5 State or province 4 City or town Part II 6 Country and ZIP or foreign postal code 11 City or town All 12 Months 15 Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage Jan 13 Country and ZIP or foreign postal code Plan Start Month (Enter 2-digit number): Employee Offer and Coverage 14 Offer of Coverage (enter required code) 12 State or province Feb Mar Apr May June July Aug Sept Oct Nov Dec 1G 16 Applicable Section 4980H Safe Harbor (enter code, if applicable) Part III Covered Individuals If Employer provided self-insured coverage, check the box and enter the information for each covered individual. (a) Name of covered individual(s) 17 18 (b) SSN Jody 111-11-3333 Judy 111-11-2222 (c) DOB (If SSN is not available) (d) Covered all 12 months (e) Months of Coverage Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 19 20 21 22 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60705M Form 1095-C (2015)

600215 Form 1095-C (2015) Page 2 Instructions for Recipient 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. 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 issuer 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 CAUTION responsibility provision. For covered individuals other than the employee listed in Part I, a Taxpayer Identification Number (TIN) may be provided instead of an SSN. 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. Part II. Employer Offer and Coverage, Lines 14 16 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 contribution for self-only coverage equal to or less than 9.5% 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. 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 self-insured employer-sponsored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box on line 14.. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum essential coverage). 1I. Your employer claimed "Qualifying Offer Transition Relief" for 2015 and for at least one month of the year you (and your spouse or dependent(s)) did not receive a Qualifying Offer. Note that your employer has also provided a contact number at which you may request further information about the health coverage, if any, you were offered (see line 10). Line 15. This line reports the employee share of the lowest-cost monthly premium for 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, or 1E is entered on line 14. If you were offered coverage but not required to contribute any amount towards the premium, this line will report a 0.00 for the amount. 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).

600316 Page 3 Form 1095-C (2015) Name of employee Part III Social security number (SSN) Covered Individuals Continuation Sheet (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not (d) Covered 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 (2015)