2.3.86. Command Code IRPOL

TIN

Entry must be 9 numeric and unedited (no hyphens) for either an SSN or an EIN. TIN cannot be 000000000 or 999999999.

TIN TYPE and VALIDITY

Entry must be 0, 1, or 3 to respectively specify Valid SSN, Invalid SSN, or EIN extraction of Information Return Documents for the TIN.

TAX YEAR

Entry must be a valid Tax Year that is available on the Command Code IRPOL Valid Tax Years, IRM 2.3.86.3 for valid Tax Years.

DOC CODE

Entry must be any DOC CODE specified by Exhibit 2.3.86-1.

1094-B

11

X

X

X

X

X

X

X

X

X

X

1094-C

12

X

X

X

X

X

X

X

X

X

X

1095-A

07

X

X

X

X

X

X

X

X

X

X

1095-B

56

X

X

X

X

X

X

X

X

X

X

1095-C

60

X

X

X

X

X

X

X

X

X

X

LINE

POSITION

DESCRIPTION AND VALIDITY

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “B”.

2.1

16

Literal Title “ACA IR 1095A, 1095B, 1095C DOCUMENTS SEARCH”

4.1

13

Literal -REQUIRED FIELDS: LAST NAME, FORM TYPE, TAX YEAR AND

5.1

8

Literal-ONE OR MORE OPTIONAL FIELDS: DOB, STATE, ZIP CODE, FIRST NAME

8.1

21

Literal-LAST NAME

10.1

21

Literal-FIRST NAME

12.1

21

Literal-FORM TYPE
(Ex. 1095A, 1095B, 1095C OR ALL)

14.1

21

Literal-TAX YEAR
(Valid Tax Years: 2014 thru 2023)

16.1

21

Literal-DOB
(YYYY-MM-DD)

18.1

21

Literal-STATE
(Use State Abbreviation)

20.1

21

Literal-ZIP CODE
5-DIGITS

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN - This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE- This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year, See IRM 2.3.86-1 for valid Tax Years.

1.6

21

DOCUMENT CODE (00) “00” retrieves all documents

1.7

27

Literal- UNIQUE-ID=>

1.8

38

nnnnnnnnnnnn Enter the UNIQUE-ID and ensure the DOCUMENT CODE is not ‘00’

2.1

24

TAX YEAR See IRM 2.3.86-1

2.2

62

TIN (Requested TIN)

4.1

28

TOTAL OF ALL DOCUMENTS

7.1 8.1 9.1

2

DOCUMENT CODE

7.2 8.2 9.2

5

FORM Form Type
See IRM 2.3.86-1

7.3 8.3 9.3

11

UNIQUE-ID

7.4 8.4 9.4

33

ALE

7.5 8.5 9.5

35

NAME FROM PART 1 OF FORM

7.6 8.6 9.6

66

DATE On-File-date

7.7 8.7 9.7

74

INFORMATION STATUS INDICATORVALUES
P-Primary Document
D-Duplicate Document
C-Corrected By Another
V-Void By Another Document
B-Blank-No Value Supplied

7.8 8.8 9.8

78

DATA RECONCILIATION CODE
Y or N

See Table Below

DATA RECONCILIATION CODES

Aggregated Group Indicator

Rule

Description

Interpretation of Data

A01

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as Yes and Aggregated Group Indicator has been marked for both monthly fields and "All 12 Months" and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated Group Indicator marked for "All 12 Months".

Consider Aggregated Group Indicator "All 12 Months" field marked

A02

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as Yes and Aggregated Group Indicator has been unmarked for all fields and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated Group Indicator marked for "All 12 Months".

Consider Aggregated Group Indicator "All 12 Months" field marked

A03

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as both Yes and No and Aggregated Group Indicator has been marked only for "All 12 Months" and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated ALE Group membership as Yes with Aggregated Group Indicator marked for "All 12 Months".

Consider Member of Aggregated ALE Group is marked as Yes with Aggregated Group Indicator "All 12 Months" marked

A04 A05

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as both Yes and No and Aggregated Group Indicator has been marked for both monthly fields and "All 12 Months" and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated ALE Group membership as Yes with Aggregated Group Indicator marked for "All 12 Months".

Consider Member of Aggregated ALE Group is marked as Yes with Aggregated Group Indicator "All 12 Months" marked

A06

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as both Yes and No and Aggregated Group Indicator has been marked for only monthly fields and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated ALE Group membership as Yes with Aggregated Group Indicator marked monthly.

Consider Member of Aggregated ALE Group is marked as Yes with Aggregated Group Indicator monthly fields marked

A07 A37

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as both Yes and No and Aggregated Group Indicator has been unmarked for all fields and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated ALE Group membership as Yes with Aggregated Group Indicator marked for "All 12 Months".

Consider Member of Aggregated ALE Group is marked as Yes with Aggregated Group Indicator "All 12 Months" marked

A08

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as both Yes and No and Aggregated Group Indicator has been marked only for "All 12 Months" and Other Members of Aggregated Group member list is empty, then consider Aggregated ALE Group membership as No.

Consider Member of Aggregated ALE Group is marked as No

A09

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as both Yes and No and Aggregated Group Indicator has been marked for both monthly fields and "All 12 Months" and Other Members of Aggregated Group member list is empty, then consider Aggregated ALE Group membership as No.

Consider Member of Aggregated ALE Group is marked as No

A10

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as both Yes and No and Aggregated Group Indicator has been marked only for monthly fields and Other Members of Aggregated Group member list is empty, then consider Aggregated ALE Group membership as No.

Consider Member of Aggregated ALE Group is marked as No

A11

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as both Yes and No and Aggregated Group Indicator has been unmarked for all fields and Other Members of Aggregated Group member list is empty, then consider Aggregated ALE Group membership as No.

Consider Member of Aggregated ALE Group is marked as No

A12 A13

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as No and Aggregated Group Indicator has been marked for both monthly field and "All 12 Months" and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated ALE Group membership as Yes with Aggregated Group Indicator marked for "All 12 Months".

Consider Member of Aggregated ALE Group is marked as Yes with Aggregated Group Indicator "All 12 Months" marked

A14

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as No and Aggregated Group Indicator has been marked only for "All 12 Months" and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated ALE Group membership as Yes with Aggregated Group Indicator marked for "All 12 Months".

Consider Member of Aggregated ALE Group is marked as Yes with Aggregated Group Indicator "All 12 Months" marked

A15

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as No and Aggregated Group Indicator has been marked only for monthly fields and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated ALE Group membership as Yes with Aggregated Group Indicator marked monthly.

Consider Member of Aggregated ALE Group is marked as Yes with Aggregated Group Indicator monthly fields marked

A16 A17

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as No and Aggregated Group Indicator has been unmarked for all fields and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated ALE Group membership as Yes with Aggregated Group Indicator marked for "All 12 Months".

Consider Member of Aggregated ALE Group is marked as Yes with Aggregated Group Indicator "All 12 Months" marked

A18

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as No and Aggregated Group Indicator has been marked only for "All 12 Months" and Other Members of Aggregated Group member list is empty, then consider Aggregated ALE Group membership as No.

Consider Member of Aggregated ALE Group is marked as No

A19

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as No and Aggregated Group Indicator has been marked for both monthly fields and "All 12 Months" and Other Members of Aggregated Group member list is empty, then consider Aggregated ALE Group membership as No.

Consider Member of Aggregated ALE Group is marked as No

A20

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as No and Aggregated Group Indicator has been marked only for monthly fields and Other Members of Aggregated Group member list is empty, then consider Aggregated ALE Group membership as No.

Consider Member of Aggregated ALE Group is marked as No

A21 A22

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is unmarked and Aggregated Group Indicator has been marked for both monthly field and "All 12 Months" and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated ALE Group membership as Yes with Aggregated Group Indicator marked for "All 12 Months".

Consider Member of Aggregated ALE Group is marked as Yes with Aggregated Group Indicator "All 12 Months" marked

A23

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is unmarked and Aggregated Group Indicator has been marked only for "All 12 Months" and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated ALE Group membership as Yes with Aggregated Group Indicator marked for "All 12 Months".

Consider Member of Aggregated ALE Group is marked as Yes with Aggregated Group Indicator "All 12 Months" marked

A24

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is unmarked and Aggregated Group Indicator has been marked only for monthly fields and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated ALE Group membership as Yes with Aggregated Group Indicator marked monthly.

Consider Member of Aggregated ALE Group is marked as Yes with Aggregated Group Indicator monthly fields marked

A25 A26

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is unmarked and Aggregated Group Indicator has been unmarked for all fields and Other Members of Aggregated Group member list contains at least one entry, then consider Aggregated ALE Group membership as Yes with Aggregated Group Indicator marked for "All 12 Months".

Consider Member of Aggregated ALE Group is marked as Yes with Aggregated Group Indicator "All 12 Months" marked

A27

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is unmarked and Aggregated Group Indicator has been marked only for "All 12 Months" and Other Members of Aggregated Group member list is empty, then consider Aggregated ALE Group membership as No.

Consider Member of Aggregated ALE Group is marked as No

A28

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is unmarked and Aggregated Group Indicator has been marked for both monthly fields and "All 12 Months" and Other Members of Aggregated Group member list is empty, then consider Aggregated ALE Group membership as No.

Consider Member of Aggregated ALE Group is marked as No

A29

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is unmarked and Aggregated Group Indicator has been marked only for monthly fields and Other Members of Aggregated Group member list is empty, then consider Aggregated ALE Group membership as No.

Consider Member of Aggregated ALE Group is marked as No

A30

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is unmarked and Aggregated Group Indicator has been unmarked for all fields and Other Members of Aggregated Group member list is empty, then consider Aggregated ALE Group membership as No.

Consider Member of Aggregated ALE Group is marked as No

A31

When Aggregated ALE Group membership is marked as Yes and Aggregated Group Indicator has been marked only for "All 12 Months" and Other Members of Aggregated Group member list has no entries, then consider Aggregated Group Indicator marked for "All 12 Months" and consider as Other ALE Members have 30 membersMonths" and Other Members of Aggregated Group member list has no entries, then consider Aggregated Group Indicator marked for "All 12 Months" and consider as Other ALE Members have 30 members.

Consider Aggregated Group Indicator "All 12 Months" marked and consider 30 members in metadata

A32 A33

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as Yes and Aggregated Group Indicator has been marked for both monthly fields and "All 12 Months" and Other Members of Aggregated Group member list has no entries, then consider Aggregated Group Indicator marked for "All 12 Months" and consider as Other ALE Members have 30 members

Consider Aggregated Group Indicator "All 12 Months" marked and consider 30 members in metadata

A34

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as Yes and Aggregated Group Indicator has been marked only for monthly fields and Other Members of Aggregated Group member list has no entries, then consider Aggregated Group Indicator marked monthly and consider as Other ALE Members have 30 members.

Consider Aggregated Group Indicator months marked and consider 30 members in metadata

A35 A36

When evaluating for data consistency of the 1094C form, when Aggregated ALE Group membership is marked as Yes and Aggregated Group Indicator has been unmarked for all monthly fields and "All 12 Months" and Other Members of Aggregated Group member list has no entries, then consider Aggregated Group Indicator marked for "All 12 Months" and consider as Other ALE Members have 30 members.

Consider Aggregated Group Indicator "All 12 Months" marked and leave unmarked for all monthly fields and consider 30 members in metadata

Minimum Essential Coverage (MEC) offer indicator

Rule

Description

Interpretation of Data

B01

When evaluating for data consistency of the 1094C form, when Minimal Essential Coverage Offer Indicator (MEC) value for "All 12 Months" has been marked as either Yes or No and all monthly rows have been marked as either Yes or No, then consider all monthly MEC indicator rows.

Consider monthly MEC offer indicator

B02

When evaluating for data consistency of the 1094C form, when Minimal Essential Coverage Offer Indicator (MEC) value for "All 12 Months" has been unmarked and all monthly rows have been unmarked, then consider all monthly rows with MEC not offered and all values marked as No.

Consider all derived MEC monthly values as No

B03

When evaluating for data consistency of the 1094C form, when Minimal Essential Coverage Offer Indicator (MEC) value for "All 12 Months" has been marked as both Yes and No and all monthly rows have been marked as either Yes or No, then consider all monthly MEC indicator rows.

Consider monthly MEC offer indicator

B04

When evaluating for data consistency of the 1094C form, when Minimal Essential Coverage Offer Indicator (MEC) value for "All 12 Months" has been as both Yes and No and all monthly rows have been unmarked, then consider all monthly rows with MEC not offered and all values marked as No.

Consider MEC not offered yearly with value marked as No

B05 B06

When evaluating for data consistency of the 1094C form, when Minimal Essential Coverage Offer Indicator (MEC) value for "All 12 Months" has been marked as either Yes or No and some monthly rows have been marked as either Yes or No and other rows have been either left unmarked or marked as both Yes and No, then consider MEC offered by month with original values and for fields that were marked Yes and No simultaneously or left blank consider them marked as No.

Consider MEC offered by month with original values and for fields that were marked Yes and No simultaneously or left blank consider them marked as No

B06

When evaluating for data consistency of the 1094C form, when Minimal Essential Coverage Offer Indicator (MEC) value for "All 12 Months" has been unmarked and some monthly rows have been marked as either Yes or No and other rows have been either left unmarked or marked as both Yes and No, then consider MEC offered by month with original values and for fields that were marked Yes and No simultaneously or left blank consider them marked as No.

Consider MEC offered by month with original values and for fields that were marked Yes and No simultaneously or left blank consider them marked as No

B07 B08

When evaluating for data consistency of the 1094C form, when Minimal Essential Coverage Offer Indicator (MEC) value for "All 12 Months" has been marked as both Yes and No and some monthly rows have been marked as either Yes or No and other rows have been either left unmarked or marked as both Yes and No, then consider MEC offered by month with original values and for fields that were marked Yes and No simultaneously or left blank consider them marked as No.

Consider MEC offered by month with original values and for fields that were marked Yes and No simultaneously or left blank consider them marked as No

B09 B10

When evaluating for data consistency of the 1094C form, when Minimal Essential Coverage Offer Indicator (MEC) value for "All 12 Months" has been marked as either Yes or No and all monthly rows have been either unmarked or marked as both Yes and No, then consider all monthly rows with MEC not offered and all values marked as No.

Consider MEC offered by month with all values marked No

B11

When evaluating for data consistency of the 1094C form, when Minimal Essential Coverage Offer Indicator (MEC) value for "All 12 Months" has been unmarked and all monthly rows have been either unmarked or marked as both Yes and No, then consider all monthly rows with MEC not offered and all values marked as No.

Consider MEC offered by month with all values marked No

B12 B13

When evaluating for data consistency of the 1094C form, when Minimal Essential Coverage Offer Indicator (MEC) value for "All 12 Months" has been marked as both Yes and No and all monthly rows have been either unmarked or marked as both Yes and No, then consider all monthly rows with MEC not offered and all values marked as No.

Consider MEC offered by month with all values marked No

FTE - Part III column (b), Form 1094-C

Rule

Description

Interpretation of Data

C01

When evaluating for data consistency of the 1094C form, when Full Time Employee (FTE) Count has a value zero or greater than zero for "All 12 Months" and all monthly rows have values greater than zero, then consider monthly values.

Consider FTE count by month and use monthly value.

C02

When evaluating for data consistency of the 1094C form, when Full Time Employee (FTE) Count has a value greater than zero for "All 12 Months" and all monthly rows have value zero, then consider FTE count of All 12 months value

Consider FTE count of All 12 months and replace all monthly rows with value zero to blank.

C03

When evaluating for data consistency of the 1094C form, when Full Time Employee (FTE) Count has a value greater than zero for "All 12 Months" and some monthly rows have value zero and the rest have blank, then consider FTE count of All 12 months value

Consider FTE count of All 12 months and replace all monthly rows with value zero to blank.

C04 C05

When evaluating for data consistency of the 1094C form, when Full Time Employee (FTE) Count has a value zero or greater than zero or blank for "All 12 Months" and some but not all monthly rows have values greater than zero, then consider monthly values as marked and consider highest monthly value for all empty monthly fields.

Consider highest monthly value to mark empty FTE fields and consider FTE count by month

FTE per Number of Total 1095-Cs filed (Line 20) on 1094-C

Rule

Description

Interpretation of Data

D01 D02

When evaluating for data consistency of the 1094C form, if Box D on line 22 is not checked and Full Time Employee (FTE) Count has a value zero or blank for "All 12 Months" and all monthly rows have either zero or blank , then all monthly values will use the greater than zero value contained in Total Number of Forms 1095C filed by ALE Member.

Consider Total Number of Form 1095C filed by and/or on behalf of ALE Member count to update all monthly values and consider FTE count by month

FTE per Total number of 1095-Cs recorded in IRDB

Rule

Description

Interpretation of Data

E01 E02

When evaluating for data consistency of the 1094C form, if Box D on line 22 is not checked and Full Time Employee (FTE) Count has a value zero or blank for "All 12 Months" and all monthly rows have either zero or blank and Total Number of Forms 1095C filed by ALE Member has a value zero or blank ,then use total number of Form1095C for the EIN from IRDB data tables count to update for all monthly values.

Consider the total number of Form 1095-C for that EIN from the IRDB data tables count to update all monthly values and consider FTE count by month

Transition Relief

Rule

Description

Interpretation of Data

F01 F02

When evaluating for data consistency of the 1094C form, when transition relief code is valid for "All 12 Months" and valid for at least one monthly row, then consider valid monthly values and for any invalid codes mark value as blank.

Consider valid monthly values and for any invalid codes mark value as blank

F03 F04

When evaluating for data consistency of the 1094C form, when transition relief code is invalid for "All 12 Months" and valid for at least one monthly row, then consider valid monthly values and for any invalid codes mark value as blank.

Consider valid monthly values and for any invalid codes mark value as blank

F05

When evaluating for data consistency of the 1094C form, when transition relief code is blank for "All 12 Months" and valid for at least one monthly row, then consider valid monthly values and for any invalid codes mark value as blank.

Consider valid monthly values and for any invalid codes mark value as blank

F06 F07

When evaluating for data consistency of the 1094C form, when transition relief code is valid for "All 12 Months" and invalid for all monthly rows, then consider the "All 12 months" value as valid and for any invalid monthly codes mark value as blank.

Consider the valid All 12 months value and change invalid monthly values to blank

F08 F09

When evaluating for data consistency of the 1094C form, when transition relief code is invalid for "All 12 Months" and invalid for all monthly rows, then consider not qualified for 4980H relief and for any invalid codes mark value as blank.

Consider monthly relief fields as not valid and for any invalid codes mark value as blank

F10

When evaluating for data consistency of the 1094C form, when transition relief code is invalid for "All 12 Months" and blank for all monthly rows, then consider not qualified for 4980H relief and for any invalid codes mark value as blank.

Consider yearly relief field as not valid and for any invalid codes mark value as blank

F11

When evaluating for data consistency of the 1094C form, when transition relief code is blank for "All 12 Months" and invalid for all monthly rows, then consider not qualified for 4980H relief and for any invalid codes mark value as blank.

Consider monthly relief fields as not valid and for any invalid codes mark value as blank

MEC offer Code (Line 14), Form 1095-C

Rule

Description

Interpretation of Data

G01 G02

When evaluating for data consistency of the 1095C form, when coverage code is valid for "All 12 Months" and valid for at least one monthly value, then consider valid monthly values and for any invalid codes mark value as blank.

Consider valid monthly values and for any invalid codes found change invalid value to blank Note: for this rule if a monthly value is changed to blank it is treated as if no offer was made.

G03 G04

When evaluating for data consistency of the 1095C form, when coverage code is invalid for "All 12 Months" and valid for at least one monthly value, then consider valid monthly values and for any invalid codes mark value as blank.

Consider valid monthly values and for any invalid codes found change invalid value to blank Note: for this rule if a monthly value is changed to blank it is treated as if no offer was made.

G05

When evaluating for data consistency of the 1095C form, when coverage code is blank for "All 12 Months" and valid for at least one monthly value, then consider valid monthly values and for any invalid codes mark value as blank.

Consider valid monthly values and for any invalid codes found change invalid value to blank Note: for this rule if a monthly value is changed to blank it is treated as if no offer was made.

G06 G07

When evaluating for data consistency of the 1095C form, when coverage code is valid for "All 12 Months" and invalid for all monthly values, then consider "All 12 months" value as valid and for any invalid monthly codes mark value as blank.

Consider the valid All 12 months value and change invalid monthly values to blank

G08 G09

When evaluating for data consistency of the 1095C form, when coverage code is invalid for "All 12 Months" and invalid for all monthly values, then consider coverage as not valid and for any invalid codes mark value as blank.

Consider monthly coverage fields as not valid and for any invalid codes found change invalid value to blank Note: for this rule if a monthly value is changed to blank it is treated as if no offer was made.

G10

When evaluating for data consistency of the 1095C form, when coverage code is invalid for "All 12 Months" and blank for all monthly values, then consider coverage as not valid and for any invalid codes mark value as blank.

Consider yearly coverage field as not valid and for any invalid codes found change invalid value to blank Note: for this rule if a monthly value is changed to blank it is treated as if no offer was made.

G11

When evaluating for data consistency of the 1095C form, when coverage code is blank for "All 12 Months" and invalid for all monthly values, then consider coverage as not valid and for any invalid codes mark value as blank.

Consider monthly coverage fields as not valid and for any invalid codes found change invalid value to blank Note: for this rule if a monthly value is changed to blank it is treated as if no offer was made.

Safe Harbors and Other Relief (Line 16), Form 1095-C

Rule

Description

Interpretation of Data

H01 H02

When evaluating for data consistency of the 1095C form, when relief code is valid for "All 12 Months" and valid for at least one monthly value, then consider valid monthly values and for any invalid codes mark value as blank.

Consider valid monthly values and for any invalid codes found change invalid value to blank

H03 H04

When evaluating for data consistency of the 1095C form, when relief code is invalid for "All 12 Months" and valid for at least one monthly value, then consider valid monthly values and for any invalid codes mark value as blank.

Consider valid monthly values and for any invalid codes found change invalid value to blank

H05

When evaluating for data consistency of the 1095C form, when relief code is blank for "All 12 Months" and valid for at least one monthly value, then consider valid monthly values and for any invalid codes mark value as blank.

Consider valid monthly values and for any invalid codes found change invalid value to blank

H06 H07

When evaluating for data consistency of the 1095C form, when relief code is valid for "All 12 Months" and invalid for all monthly values, then consider "All 12 months" value as valid and for any invalid monthly codes mark value as blank.

Consider the valid All 12 months value and change invalid monthly values to blank

H08 H09

When evaluating for data consistency of the 1095C form, when relief code is invalid for "All 12 Months" and invalid for all monthly values, then consider monthly relief code as not valid and for any invalid codes mark value as blank.

Consider monthly relief fields as not valid and for any invalid codes found change invalid value to blank

H10

When evaluating for data consistency of the 1095C form, when relief code is invalid for "All 12 Months" and blank for all monthly values, then consider yearly relief code as not valid and for any invalid codes mark value as blank.

Consider yearly relief field as not valid and for any invalid codes found change invalid value to blank

H11

When evaluating for data consistency of the 1095C form, when relief code is blank for "All 12 Months" and invalid for all monthly values, then consider monthly relief code as not valid and for any invalid codes mark value as blank.

Consider monthly relief fields as not valid and for any invalid codes found change invalid value to blank

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year
See IRM 2.3.86-1

1.6

17

DOCUMENT CODE

1.7

31

REQUESTED TAX YEAR

2.1

16

DOCUMENT CODE DC 11

3.1

17

DOCUMENT TYPE(1094-B)

3.2

43

ON FILE DATE MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

53

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

4.1

2

LITERAL NAMES:
 FILER DATA

4.2

22

FILER NINE-DIGIT (EIN)

Box 2

4.3

58

SUBMITTED TO IRS
‘PAPER’ or ‘ELECTRONICALLY’

5.1
Thru
11.3

2

FILER’S DATA
NAME, ADDRESS, CITY, STATE, ZIP CODE, COUNTRY
(If foreign address, “STATE” is replaced with “CNTRY”, “ZIP” by “PLCD”, and “PROV’ will follow when appropriate.)

Box 1
Box 5
Box 6
Box 7
Box 8

5.2

58

LITERAL CONTACT INFO

6.2

44

CONTACT NAME

Box 3

7.2

45

CONTACT TELEPHONE

Box 4

20.1

11

TAX YEAR
See IRM 2.3.86-1

20.2

37

FILED – RECEIVED ON

21.1

38

TOTAL 1095-B FORMS TRANSMITTED WITH FORM 1094-B.

Box 9

22.1

38

TOTAL 1095-B FORMS PROCESSED

24.1

35

PAGE NUMBER OF TOTAL PAGES - The page number of the last document of the individual document display.

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE -

1.7

31

REQUESTED TAX YEAR

2.1

16

DOCUMENT CODE DC 12

3.1

17

DOCUMENT TYPE(1094-C)

3.2

42

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

53

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

4.1

2

LITERAL NAMES:
 EMPLOYER DATA

4.2

22

EMPLOYER NINE-DIGIT (EIN)

Box 2

4.3

58

SUBMITTED TO IRS
‘PAPER’ or ‘ELECTRONICALLY’

5.1
Thru
11.3

2

ALE DATA
NAME, ADDRESS, CITY, STATE, ZIP CODE, COUNTRY
(If foreign address, “STATE” is replaced with “CNTRY”, “ZIP” by “PLCD”, and “PROV’ will follow when appropriate.)

Box 1
Box 3
Box 4
Box 5
Box 6

5.2

58

LITERAL: CONTACT INFO

6.2

44

CONTACT NAME

Box 7

7.2

45

CONTACT TELEPHONE

Box 8

12.1

11

GOVERNMENT ENTITY DATA

12.2

27

EIN(Employer Identification Number)

Box 10

13.1
Thru
19.3

2

DESIGNATED GOVERNMENT ENTITY NAME, ADDRESS,CITY,STATE,ZIP CODE, COUNTRY

Box 9, 11-14

13.2

58

LITERAL: CONTACT INFO

14.1

2

CONTACT NAME

Box 15

15.2

45

CONTACT TELEPHONE

Box 16

20.1

11

TAX YEAR

20.2

37

FILED – RECEIVED ON

21.1

38

TOTAL 1095-C FORMS TRANSMITTED

Box 18

22.1

38

TOTAL 1095-C FORMS PROCESSED

24.1

35

PAGE NUMBER OF TOTAL PAGES - The page number of the last document of the individual document display.

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE

1.7

32

REQUESTED TAX YEAR

2.1

16

DOCUMENT CODE DC 12

3.1

17

DOCUMENT TYPE– (1094-C)

3.2

43

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

54

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

4.1

2

LITERAL NAMES:
 EMPLOYER DATA

4.2

22

EIN

Box 2

4.3

58

SUBMITTED TO IRS
‘PAPER’ or ‘ELECTRONICALLY’

5.1

2

EMPLOYER NAME

Box 1

12.1

42

AUTHORITATIVE TRANSMITTAL FOR THIS ALE

Box19

13.1

47

ALE MEMBER - A MEMBER OF AGGREGATED ALE GROUP

Box 21

14.1

2

LITERAL: CERTIFICATIONS OF ELIGIBILITY

15.1

32

QUALIFYING OFFER METHOD

Box 22a

16.1

50

RESERVED

Box 22b

17.1

37

RESERVED

Box 22c

18.1

22

98% OFFER METHOD

Box 22d

21.1

38

TOTAL 1095-C FORMS FILED FOR ALE MEMBER

Box 20

24.1

35

PAGE NUMBER OF TOTAL PAGES - The page number of the last document of - the individual document display

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE

1.7

32

REQUESTED TAX YEAR

2.1

16

DOCUMENT CODE DC 12

3.1

17

DOCUMENT TYPE– (1094-C)

3.2

43

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

54

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

4.1

2

LITERAL EMPLOYER DATA  

4.2

22

EIN

Box 2

4.3

58

SUBMITTED TO IRS
‘PAPER’ or ‘ELECTRONICALLY’

5.1

2

EMPLOYER NAME

Box 1

9.1

13

MEC (MINIMUM ESSENTIAL COVERAGE OFFER INDICATOR) ALL MONTHS
Yes, No, or Blank

Box 23a

9.2

27

AGG (AGGREGATED GROUP INDICATOR) ALL MONTHS
Yes or Blank

Box 23d

9.3

37

RELIEF (SECTION 4980H TRANSITION RELIEF INDICATOR) ALL MONTHS
A, B, or Blank

Box 23e

9.4

43

FTE (FULL-TIME EMPLOYEE COUNT FOR ALE MEMBER) ALL MONTHS
Blank, Zero, or a Positive Number

Box 23b

9.5

59

TOT EMP COUNT (TOTAL EMPLOYEE COUNT FOR ALE MEMBER) ALL MONTHS
Blank, Zero, or a Positive Number

Box 23c

10.1

13

MEC (MINIMUM ESSENTIAL COVERAGE OFFER INDICATOR) JAN
Yes, No, or Blank

Box 24a

10.2

27

AGG (AGGREGATED GROUP INDICATOR) JAN
Yes or Blank

Box 24d

10.3

37

RELIEF (SECTION 4980H TRANSITION RELIEF INDICATOR) JAN
A, B, or Blank

Box 24e

10.4

43

FTE (FULL-TIME EMPLOYEE COUNT FOR ALE MEMBER) JAN
Blank, Zero, or Positive Number

Box 24b

10.5

59

TOT EMP COUNT (TOTAL EMPLOYEE COUNT FOR ALE MEMBER) JAN
Blank, Zero, or Positive Number

Box 24c

11.1

13

MEC (MINIMUM ESSENTIAL COVERAGE OFFER INDICATOR) FEB
Yes, No, or Blank

Box 25a

11.2

27

AGG (AGGREGATED GROUP INDICATOR) FEB
Yes or Blank

Box 25d

11.3

37

RELIEF (SECTION 4980H TRANSITION RELIEF INDICATOR) FEB
A, B, or Blank

Box 25e

11.4

43

FTE (FULL-TIME EMPLOYEE COUNT FOR ALE MEMBER) FEB
Blank, Zero, or Positive Number

Box 25b

11.5

59

TOT EMP COUNT (TOTAL EMPLOYEE COUNT FOR ALE MEMBER) FEB
Blank, Zero, or Positive Number

Box 25c

12.1

13

MEC (MINIMUM ESSENTIAL COVERAGE OFFER INDICATOR) MAR
Yes, No, or Blank

Box 26a

12.2

27

AGG (AGGREGATED GROUP INDICATOR) MAR
Yes or Blank

Box 26d

12.3

37

RELIEF IND (SECTION 4980H TRANSITION RELIEF INDICATOR) MAR
A, B, or Blank

Box 26e

12.4

43

FTE (FULL-TIME EMPLOYEE COUNT FOR ALE MEMBER) MAR
Blank, Zero, or Positive Number

Box 26b

12.5

59

TOT EMP COUNT (TOTAL EMPLOYEE COUNT FOR ALE MEMBER) MAR
Blank, Zero, or Positive Number

Box 26c

13.1

13

MEC (MINIMUM ESSENTIAL COVERAGE OFFER INDICATOR) APR
Yes, No, or Blank

Box 27a

13.2

27

AGG (AGGREGATED GROUP INDICATOR) APR
Yes or Blank

Box 27d

13.3

37

RELIEF IND (SECTION 4980H TRANSITION RELIEF INDICATOR) APR
A, B, or Blank

Box 27e

13.4

43

FTE (FULL-TIME EMPLOYEE COUNT FOR ALE MEMBER) APR
Blank, Zero, or Positive Number

Box 27b

13.5

59

TOT EMP COUNT (TOTAL EMPLOYEE COUNT FOR ALE MEMBER) APR
Blank, Zero, or Positive Number

Box 27c

14.1

13

MEC (MINIMUM ESSENTIAL COVERAGE OFFER INDICATOR) MAY
Yes, No, or Blank

Box 28a

14.2

27

AGG (AGGREGATED GROUP INDICATOR) MAY
Yes or Blank

Box 28d

14.3

37

RELIEF IND (SECTION 4980H TRANSITION RELIEF INDICATOR) MAY
A, B, or Blank

Box 28e

14.4

43

FTE (FULL-TIME EMPLOYEE COUNT FOR ALE MEMBER) MAY
Blank, Zero, or Positive Number

Box 28b

14.5

59

TOT EMP COUNT (TOTAL EMPLOYEE COUNT FOR ALE MEMBER) MAY
Blank, Zero, or Positive Number

Box 28c

15.1

13

MEC (MINIMUM ESSENTIAL COVERAGE OFFER INDICATOR) JUN
Yes, No, or Blank

Box 29a

15.2

27

AGG (AGGREGATED GROUP INDICATOR) JUN
Yes or Blank

Box 29d

15.3

37

RELIEF IND (SECTION 4980H TRANSITION RELIEF INDICATOR) JUN
A, B, or Blank

Box 29e

15.4

43

FTE (FULL-TIME EMPLOYEE COUNT FOR ALE MEMBER) JUN
Blank, Zero, or Positive Number

Box 29b

15.5

59

TOT EMP COUNT (TOTAL EMPLOYEE COUNT FOR ALE MEMBER) JUN
Blank, Zero, or Positive Number

Box 29c

16.1

13

MEC (MINIMUM ESSENTIAL COVERAGE OFFER INDICATOR) JUL
Yes, No, or Blank

Box 30a

16.2

27

AGG (AGGREGATED GROUP INDICATOR) JUL
Yes or Blank

Box 30d

16.3

37

RELIEF IND (SECTION 4980H TRANSITION RELIEF INDICATOR) JUL
A, B, or Blank

Box 30e

16.4

43

FTE (FULL-TIME EMPLOYEE COUNT FOR ALE MEMBER) JUL
Blank, Zero, or Positive Number

Box 30b

16.5

59

TOT EMP COUNT (TOTAL EMPLOYEE COUNT FOR ALE MEMBER) JUL
Blank, Zero, or Positive Number

Box 30c

17.1

13

MEC (MINIMUM ESSENTIAL COVERAGE OFFER INDICATOR) AUG
Yes, No, or Blank

Box 31a

17.2

27

AGG (AGGREGATED GROUP INDICATOR) AUG
Yes or Blank

Box 31d

17.3

37

RELIEF IND (SECTION 4980H TRANSITION RELIEF INDICATOR) AUG
A, B, or Blank

Box 31e

17.4

43

FTE (FULL-TIME EMPLOYEE COUNT FOR ALE MEMBER) AUG
Blank, Zero, or Positive Number

Box 31b

17.5

59

TOT EMP COUNT (TOTAL EMPLOYEE COUNT FOR ALE MEMBER) AUG
Blank, Zero, or Positive Number

Box 31c

18.1

13

MEC (MINIMUM ESSENTIAL COVERAGE OFFER INDICATOR) SEP
Yes, No, or Blank

Box 32a

18.2

27

AGG (AGGREGATED GROUP INDICATOR) SEP
Yes or Blank

Box 32d

18.3

37

RELIEF IND (SECTION 4980H TRANSITION RELIEF INDICATOR) SEP
A, B, or Blank

Box 32e

18.4

43

FTE (FULL-TIME EMPLOYEE COUNT FOR ALE MEMBER) SEP
Blank, Zero, or Positive Number

Box 32b

18.5

59

TOT EMP COUNT (TOTAL EMPLOYEE COUNT FOR ALE MEMBER) SEP
Blank, Zero, or Positive Number

Box 32c

19.1

13

MEC (MINIMUM ESSENTIAL COVERAGE OFFER INDICATOR) OCT
Yes, No, or Blank

Box 33a

19.2

27

AGG (AGGREGATED GROUP INDICATOR) OCT
Yes or Blank

Box 33d

19.3

37

RELIEF IND (SECTION 4980H TRANSITION RELIEF INDICATOR) OCT
A, B, or Blank

Box 33e

19.4

43

FTE (FULL-TIME EMPLOYEE COUNT FOR ALE MEMBER) OCT
Blank, Zero, or Positive Number

Box 33b

19.5

59

TOT EMP COUNT (TOTAL EMPLOYEE COUNT FOR ALE MEMBER) OCT
Blank, Zero, or Positive Number

Box 33c

20.1

13

MEC (MINIMUM ESSENTIAL COVERAGE OFFER INDICATOR) NOV
Yes, No, or Blank

Box 34a

20.2

27

AGG (AGGREGATED GROUP INDICATOR) NOV
Yes or Blank

Box 34d

20.3

37

RELIEF IND (SECTION 4980H TRANSITION RELIEF INDICATOR) NOV
A, B, or Blank

Box34e

20.4

43

FTE (FULL-TIME EMPLOYEE COUNT FOR ALE MEMBER) NOV
Blank, Zero, or Positive Number

Box34b

20.5

59

TOT EMP COUNT (TOTAL EMPLOYEE COUNT FOR ALE MEMBER) NOV
Blank, Zero, or Positive Number

Box 34c

21.1

13

MEC (MINIMUM ESSENTIAL COVERAGE OFFER INDICATOR) DEC
Yes, No, or Blank

Box 35a

21.2

27

AGG (AGGREGATED GROUP INDICATOR) DEC
Yes or Blank

Box 35d

21.3

37

RELIEF IND (SECTION 4980H TRANSITION RELIEF INDICATOR) DEC
A, B, or Blank

Box 35e

21.4

43

FTE (FULL-TIME EMPLOYEE COUNT FOR ALE MEMBER) DEC
Blank, Zero, or Positive Number

Box 35b

21.5

59

TOT EMP COUNT (TOTAL EMPLOYEE COUNT FOR ALE MEMBER) DEC
Blank, Zero, or Positive Number

Box 35c

24.1

35

PAGE NUMBER OF TOTAL PAGES - The page number of the last document of - the individual document display

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE

1.7

32

REQUESTED TAX YEAR

2.1

16

DOCUMENT CODE DC 12

3.1

17

DOCUMENT TYPE– (1094-C)

3.2

43

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

54

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

4.1

2

LITERAL EMPLOYER DATA  

4.2

27

EIN

Box 2

4.2

58

SUBMITTED TO IRS
‘PAPER’ or ‘ELECTRONICALLY’

5.1

2

EMPLOYER NAME

Box 1

7.1

2

LITERAL OTHER ALE MEMBERS OF ALE GROUP

8.1, 8.2, 10.1, 10.2, 12.1, 12.2, 14.1, 14.2, 16.1, 16.2, 18.1, 18.2, 20.1, 20.2, 22.1, 22.2

2, 42

OTHER ALE MEMBERS OF ALE GROUP

Box 36 - Box 65

9.1, 9.2, 11.1, 11.2, 13.1, 13.2, 15.1, 15.2, 17.1, 17.2, 19.1, 19.2, 21.1, 21.2, 23.1, 23.2

7, 47

EIN

Box 36 - Box 65

24.1

35

PAGE NUMBER OF TOTAL PAGES - The page number of the last document of - the individual document display

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE

1.7

32

REQUESTED TAX YEAR

2.1

16

DOCUMENT CODE DC 12

3.1

17

DOCUMENT TYPE– (1094-C)

3.2

43

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

54

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

6.1

2

DATA RECONCILIATION CODES FOR AGGREGATED GROUP INDICATORS  (Potentially codes A01 thru A26 can be listed)

9.1

2

DATA RECONCILATION CODES FOR MINIMUM ESSENTIAL COVERAGE (MEC) OFFER INDICATORS (Potentially code B04 can be listed)

Box 2

12.1

2

DATA RECONCILIATION CODES FOR FTE – PART III COLUMN B, FORM 11094-C INDICATORS (Potentially codes C01 and/or C03 can be listed)

15.1

2

DATA RECONCILIATION CODES FOR FTE PER NUMBER OF TOTAL 1095-CS FILED (LINE 20) ON 1094-C (Potentially D01 code can be listed)

18.1

2

DATA RECONCILIATION CODES FOR FTE PER TOTAL NUMBER OF 1095-CS RECORDED IN IRDB (Potentially E01 code can be listed)

21.1

2

DATA RECONCILIATION CODES FOR TRANSITION RELIEF INDICATORS (Potentially codes F01, F06, F07 can be listed)

23.1

2

EXHIBIT 2.3.86.2 JOB AIDE EXHIBIT

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE

1.7

32

REQUESTED TAX YEAR

2.1

16

DOCUMENT CODE DC 07

3.1

17

DOCUMENT TYPE– (1095-A)

3.2

43

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

54

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

4.1

2

LITERAL RECIPIENT DATA

4.2

27

SSN

Box 5

4.3

58

SUBMITTED TO IRS
‘PAPER’ or ‘ELECTRONICALLY’

5.1

2

RECIPIENT’S DATA
Name, Address, city, State, Zip, and Country

BOXES 4, 12, 13, 14, 15

5.2

49

RECIPIENT’S DATE OF BIRTH (DOB)

BOX 6

12

2

LITERAL SPOUSE DATA

12.2

27

SSN

Box 8

13.1

2

SPOUSE NAME
(When no spouse information is on the form, “SPOUSE DATA: NONE” will appear. The following SSN, Name, DOB will not appear).

Box 7

13.2

49

SPOUSE’S DATE OF BIRTH (DOB)

Box 9

15.1

26

MARKETPLACE IDENTIFIER

Box 1

16.1

29

ASSIGNED POLICY NUMBER

Box 2

17.1

25

POLICY ISSUER

Box 3

18.1

24

POLICY START-DATE

Box 10

19.1

30

POLICY TERMINATION-DATE

Box 11

24

21

PAGE NUMBER OF TOTAL PAGES - The page number of the last document of— the individual document display

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE

1.7

32

REQUESTED TAX YEAR

2.1

16

DOCUMENT CODE DC 07

3.1

17

DOCUMENT TYPE– (1095-A)

3.2

43

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

54

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

4.1

2

LITERAL RECIPIENT DATA

4.2

27

SSN

Box 5

4.3

58

SUBMITTED TO IRS
‘PAPER’ or ‘ELECTRONICALLY’

5.1

2

RECIPIENT NAME

Box 4

5.2

47

RECIPIENT DOB

Box 6

7.1

2

LITERAL: COVERED INDIVIDUALS, SSN, DOB

8.1, 10.1, 12.1, 14.1, 16.1, 18.1, 20.1

2

COVERED INDIVIDUAL NAME

Box 16a-20a

8.2, 10.2, 12.2, 14.2, 16.2, 18.2, 20.2

38

COVERED INDIVIDUAL SSN

Box 16b-20b

8.3, 10.3, 12.3, 14.3, 16.3, 18.3, 20.3

52

COVERED INDIVIDUAL DOB

Box 16c-20c

9.1, 11.1, 13.1, 15.1, 17.1, 19.1, 21.1

14

COVERAGE START DATE

Boxes16D-20D

9.2, 11.2, 13.2, 15.2, 17.2, 19.2, 21.2

44

COVERAGE TERMINATION DATE

Boxes 16E-20E

24

21

PAGE NUMBER OF TOTAL PAGES - The page number of the last document of— the individual document display

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE

1.7

32

REQUESTED TAX YEAR

2.1

16

DOCUMENT CODE DC 07

3.1

17

DOCUMENT TYPE– (1095-A)

3.2

43

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

54

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

4.1

2

LITERAL NAME: RECIPIENT DATA

4.2

27

SSN

Box 5

4.3

58

SUBMITTED TO IRS
‘PAPER’ or ‘ELECTRONICALLY’

5.1

2

RECIPIENT NAME

Box 4

5.2

49

RECIPIENT DOB

Box 6

7.1

12

LITERAL NAME: ENROLLMT

7.2

29

LITERAL NAME: SLCSP

7.3

46

LITERAL NAME: APCT

8.1

13

LITERAL NAME: PREM

8.2

30

LITERAL NAME: AMT

8.3

46

LITERAL NAME:AMT

9.1

14

JAN MONTHLY PREMIUM AMOUNT

Box 21a

9.2

30

JAN MONTHLY SECOND LOWEST COST SILVER PLAN (SLCSP)

Box 21b

9.3

45

JAN MONTHLY ADVANCE PAYMENT OF PREMIUM TAX CREDIT

Box 21c

10.1

14

FEB MONTHLY PREMIUM AMOUNT

Box 22a

10.2

30

FEB MONTHLY SECOND LOWEST COST SILVER PLAN (SLCSP)

Box 22b

10.3

45

FEB MONTHLY ADVANCE PAYMENT OF PREMIUM TAX CREDIT

Box 22c

11.1

14

MAR MONTHLY AMOUNT

Box 23a

11.2

30

MAR MONTHLY SECOND LOWEST COST SILVER PLAN (SLCSP)

Box 23b

11.3

45

MAR MONTHLY ADVANCE PAYMENT OF PREMIUM TAX CREDIT

Box 23c

12.1

14

APR MONTHLY PREMIUM AMOUNT

Box 24a

12.2

30

APR MONTHLY SECOND LOWEST COST SILVER PLAN (SLCSP)

Box 24b

12.3

45

APR MONTHLY ADVANCE PAYMENT OF PREMIUM TAX CREDIT

Box 24c

13.1

14

MAY MONTHLY PREMIUM AMOUNT

Box 25a

13.2

30

MAY MONTHLY SECOND LOWEST COST SILVER PLAN (SLCSP)

Box 25b

13.3

45

MAY MONTHLY ADVANCE PAYMENT OF PREMIUM TAX CREDIT

Box 25c

14.1

14

JUN MONTHLY PREMIUM AMOUNT

Box 26a

14.2

30

JUN MONTHLY SECOND LOWEST COST SILVER PLAN (SLCSP)

Box 26b

14.3

45

JUN MONTHLY ADVANCE PAYMENT OF PREMIUM TAX CREDIT

Box 26c

15.1

14

JUL MONTHLY PREMIUM AMOUNT

Box 27a

15.2

30

JUL MONTHLY SECOND LOWEST COST SILVER PLAN (SLCSP)

Box 27b

15.3

45

JUL MONTHLY ADVANCE PAYMENT OF PREMIUM TAX CREDIT

Box 27c

16.1

14

AUG MONTHLY PREMIUM AMOUNT

Box 28a

16.2

30

AUG MONTHLY SECOND LOWEST COST SILVER PLAN (SLCSP)

Box 28b

16.3

45

AUG MONTHLY ADVANCE PAYMENT OF PREMIUM TAX CREDIT

Box 28c

17.1

14

SEP MONTHLY PREMIUM AMOUNT

Box 29a

17.2

30

SEP MONTHLY SECOND LOWEST COST SILVER PLAN (SLCSP)

Box 29b

17.3

45

SEP MONTHLY ADVANCE PAYMENT OF PREMIUM TAX CREDIT

Box 29c

18.1

14

OCT MONTHLY PREMIUM AMOUNT

Box 30a

18.2

30

OCT MONTHLY SECOND LOWEST COST SILVER PLAN (SLCSP)

Box 30b

18.3

45

OCT MONTHLY ADVANCE PAYMENT OF PREMIUM TAX CREDIT

Box 30c

19.1

14

NOV MONTHLY PREMIUM AMOUNT

Box 31a

19.2

30

NOV MONTHLY SECOND LOWEST COST SILVER PLAN (SLCSP)

Box 31b

19.3

45

NOV MONTHLY ADVANCE PAYMENT OF PREMIUM TAX CREDIT

Box 31c

20.1

14

DEC MONTHLY PREMIUM AMOUNT

Box 32a

20.2

30

DEC MONTHLY SECOND LOWEST COST SILVER PLAN (SLCSP)

Box 32b

20.3

45

DEC MONTHLY ADVANCE PAYMENT OF PREMIUM TAX CREDIT

Box 32c

22.1

10

ANNUAL TOTAL MONTHLY PREMIUM AMOUNT

Box 33a

22.2

26

TOTAL MONTHLY SECOND LOWEST COST SILVER PLAN (SLCSP)

Box 33b

22.3

41

TOTAL MONTHLY ADVANCE PAYMENT OF PREMIUM TAX CREDIT

Box 33c

24

21

PAGE NUMBER OF TOTAL PAGES - The page number of the last document of— the individual document display

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE

1.7

32

REQUESTED TAX YEAR

2.1

16

DOCUMENT CODE DC 56

3.1

17

DOCUMENT TYPE– (1095-B)

3.2

43

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

54

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

4.1

2

LITERAL RESPONSIBLE INDIVIDUAL DATA

4.2

27

SSN or TIN

Box 2

4.3

58

SUBMITTED TO IRS
‘PAPER’ or ‘ELECTRONICALLY’

5.1
Thru
11.3

2

RESPONSIBLE INDIVIDUAL DATA
NAME, ADDRESS, CITY, STATE, ZIP CODE, COUNTRY

(If foreign address, “ STATE” is replaced with “CNTRY”, “ZIP” by “PLCD”, and “PROV” will follow when appropriate)

Box 1
Box 4
Box 5
Box 6
Box 7

5.2

49

RESPONSIBLE INDIVIDUAL’S DOB
(If SSN or other TIN is not available)

Box 3

12.1

2

LITERAL EMPLOYER DATA

12.2

27

EIN(Employer Identification Number

Box 11

12.3

44

LITERAL ISSUER/PROVIDER

12.4

70

ISSUER/PROVIDER (EIN)

Box 17

13.1, 14.1, 15.1, 16.1, 17.1, 18.1, 19.1, 19.219.3

2

EMPLOYER
NAME, ADDRESS,CITY,STATE,ZIP CODE, COUNTRY

Box 10
Box 12
Box 13
Box 14
Box 15

13.2, 14.2, 15.2, 16.2, 17.2, 18.2, 19.4, 19.5, 19.6

44

ISSUER/PROVIDER INFORMATION NAME, ADDRESS,CITY,STATE,ZIP CODE, COUNTRY

Box 16
Box 19
Box 20
Box 21
Box 22

20

53

CONTACT TELEPHONE NUMBERTelephone number the individual seeking additional information may call.

Box 18

21

14

SMALL BUSINESS HEALTH PROGRAM (S.H.O.P.) ID

Note: This line is reserved

22

20

ORIGIN OF POLICY
A. Small Business Health Options Program (SHOP).
B. Employer-sponsored coverage.
C. Government-sponsored program.
D. Individual market insurance.
E. Multiemployer plan.
F. Other Designated minimum essential coverage

Box 8

24

21

PAGE NUMBER OF TOTAL PAGES - The page number of the last document of— the individual document display

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE

1.7

32

REQUESTED TAX YEAR

2.1

16

DOCUMENT CODE DC 56

3.1

17

DOCUMENT TYPE– (1095-B)

3.2

43

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

54

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

4.1

2

LITERAL RESPONSIBLE INDIVIDUAL DATA  

4.2

27

RESPONSIBLE INDIVIDUAL
(SSN)of the responsible individual.

Box 2

4.3

58

SUBMITTED TO IRS
‘PAPER’ or ‘ELECTRONICALLY’

5.1

2

RESPONSIBLE INDIVIDUAL NAME

Box 1

5.2

47

RESPONSIBLE INDIVIDUAL DOB

Box 3

7.1

2

LITERAL COVERED INDIVIDUALS:, SSN, DOB

8.1, 10.1, 12.1, 14.1, 16.1, 18.1, 20.1

2

COVERED INDIVIDUAL NAME
(If more than 7 names press enter to continue)

Box 23a

8.2, 10.2, 12.2, 14.2, 16.2, 18.2, 20.2

38

SSN or TIN

Box 23b

8.3, 10.3, 12.3, 14.3, 16.3, 18.3, 20.3

50

DATE OF BIRTH (DOB)
(If SSN or other TIN is not available)

Box 23c

9.1, 11.1, 13.1, 15.1, 17.1, 19.1, 21.1

6

ALL
Check this box if all 12 months had coverage.

Box 23d

9.1, 11.1, 13.1, 15.1, 17.1, 19.1, 21.1

13,19,25,31,37, 43, 49, 55,61, 67, 73, 79

MONTHS
JAN, FEB ,MAR, APR, MAY, JUN, JUL, AUG, SEP, OCT, NOV, DEC

Box 23e

24

21

PAGE NUMBER OF TOTAL PAGES - The page number of the last document of— the individual document display

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default..

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE

1.7

32

REQUESTED TAX YEAR

2.3

16

DOCUMENT CODE DC 60

3.1

17

DOCUMENT TYPE– (1095-C)

3.2

43

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

54

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

4.1

2

LITERAL EMPLOYEE DATA  

4.2

27

SOCIAL SECURITY NUMBER (SSN)

Box 2

4.3

58

SUBMITTED TO IRS
‘PAPER’ or ‘ELECTRONICALLY’

5.1
Thru
11.3

2

EMPLOYEE DATA
NAME, ADDRESS, CITY, STATE, ZIP CODE, COUNTRY
(If foreign address, “STATE” is replaced with “CNTRY”, “ZIP” by “PLCD”, and “PROV’ will follow when appropriate).

Box 1
Box 3
Box 4
Box 5
Box 6

12.1

2

LITERAL EMPLOYER DATA

12.2

27

EIN(Employer Identification Number)

Box 8

13.1
Thru
19.3

2

EMPLOYER NAME
ADDRESS
CITY
STATE
ZIP CODE
COUNTRY

Box7
Box 9
Box 11
Box 12
Box 13

13.2

54

CONTACT TELEPHONE

Box 10

19.4

57

SELF-INSURED
Yes - if box is checked Self-Insured.
No - if box is not checked.

Part III

24

21

PAGE NUMBER OF TOTAL PAGES - The page number of the last document of— the individual document display

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE

1.7

32

REQUESTED TAX YEAR

2.2

16

DOCUMENT CODE DC 60

3.1

17

DOCUMENT TYPE– (1095-C)

3.2

43

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

54

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

4.1

2

LITERAL EMPLOYEE DATA

4.2

27

EMPLOYEE SSN NUMBER

Box 2

4.3

58

SUBMITTED TO IRS
‘PAPER’ or ‘ELECTRONICALLY’

5.1

2

EMPLOYEE NAME

Box 1

7.1

2

LITERAL EMPLOYEE OFFER AND COVERAGE

8.1

20

PLAN START MONTH

9.1

13, 33, 58

LITERAL: OFFER COVERAGE, *LOWEST COST, EXCLUSION

10.1Thru22.1

18

OFFER COVERAGE
See Form 1095-C

Part II Line 14 Instructions

10.2Thru22.2

36

*LOWEST COST
See Form 1095-C

Part II Line 15 Instructions

10.2Thru22.2

61

EXCLUSION
See Form 1095-C

Part II Line 16 Instructions

24

21

PAGE NUMBER OF TOTAL PAGES - The page number of the last document of— the individual document display

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE

1.7

32

REQUESTED TAX YEAR

2.2

16

DOCUMENT CODE DC 60

3.1

17

DOCUMENT TYPE– (1095-C)

3.2

43

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

54

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

4.1

2

LITERAL EMPLOYEE DATA  

4.2

27

EMPLOYEE SSN
(SSN)

Box 2

4.3

58

SUBMITTED TO IRS
‘PAPER’ or ‘ELECTRONICALLY’

5.1

2

EMPLOYEE NAME

Box 1

7.1

2

LITERAL:COVERED INDIVIDUALS, SSN, DOB

8.1, 10.1, 12.1, 14.1, 16.1, 18.1, 20.1

2

COVERED INDIVIDUAL NAME
(If more than 8 names press enter to continue)

Box 23a

8.2, 10.2, 12.2, 14.2, 16.2, 18.2, 20.2

38

SOCIAL SECURITY NUMBER (SSN)

Box 23b

8.3, 10.3, 12.3, 14.3, 16.3, 18.3, 20.3

50

DATE OF BIRTH (DOB)

Box 23c

9.1, 11.1, 13.1, 15.1, 17.1, 19.1, 21.1

6

ALL
Check this box if all 12 months had coverage.

Box 23d

9.1, 11.1, 13.1, 15.1, 17.1, 19.1, 21.1

13,19,25,31,37,43,49,55,61,67,73,79

MONTHS
JAN,FEB,MAR,APR,MAY,JUN,JUL,AUG,SEP OCT,NOV,DEC

Box 23e

24

21

PAGE NUMBER OF TOTAL PAGES - The page number of the last document of— the individual document display

LINE

POSITION

DESCRIPTION AND VALIDITY

PAPER FORM REFERENCE

1.1

1

COMMAND CD

1.2

6

COMMAND DEFINER CD- “A”NOTE: Errors are treated as if you had entered the default.

1.3

7

REQUEST TIN -This Field recapitulates the requested TIN you entered

1.4

16

VALIDITY CODE -This Field recapitulates the VALIDITY CODE you entered.

1.5

17

TAX YEAR - Requested Tax Year

1.6

21

DOCUMENT CODE

1.7

32

REQUESTED TAX YEAR

2.1

16

DOCUMENT CODE DC 60

3.1

17

DOCUMENT TYPE– (1095-C)

3.2

43

ON FILE DATE - MM/DD/YYYY
Date this document passed final valid format checks and became part of the IRDB. The document may not become available online immediately.

3.3

54

TYPE OF SUBMISSION:
 CORRECTED/ORIGINAL

6.1

2

DATA RECONCILIATION CODES FOR OFFER OF COVERAGE CODE (LINE 14), FORM 1095-C INDICATORS (Potentially codes G01, G04,G05,G06 can be listed)

9.1

2

DATA RECONCILATION CODES FOR SAFE HARBOR AND OTHER RELIEF (LINE 16), FORM 1095-C INDICATORS (Potentially code H01, H04, H06 can be listed)

Box 2

23.1

2

EXHIBIT 2.3.86.2 JOB AIDE EXHIBIT