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FORM 1095-B
Click on the individual boxes below for specific IRS Instructions
Part I: Responsible Individual |
Part II: Employer-Sponsored Coverage |
Lines 10-15, Name, EIN, and Complete Mailing Address for the Employer Sponsoring the Coverage |
Part III: Issuer or Other Coverage Provider |
Lines 16-22, Name, EIN, and Complete Mailing Address of Issuer/ Other Coverage |