Internal Revenue Manual
IRM 2.3.86 — Command Code IRPOL
Part 2. Information Technology
Chapter 3. IDRS Terminal Responses Section 86. Command Code IRPOL 2.3.86 Command Code IRPOL Manual Transmittal December 17, 2025 Purpose (1) This transmits revised IRM 2.3.86, Information Returns Processing Online (IRPOL) Command Code allows IDRS users to search, access, and display Affordable Care Act (ACA)forms - from insurance companies, employers, and ACA marketplaces - filed to the IRS in accord to the Patient Protection and Affordable Care Act (ACA) of 2010. Material Changes (1) Exhibit 2.3.86-1 - Document Code Availability Tax Year increased. (2) Updated the new definition of Legacy. (3) Summary: Changes were made for TY2025. All Tax years reference TY2025 - TY2016 unless otherwise listed. Effect on Other Documents IRM 2.3.86 dated March 3, 2025, is superseded. Audience IDRS USERS, SB/SE. Effective Date (02-02-2026) Kaschit Pandya Acting Chief Information Officer
Program Scope and Objectives
2.3.86.1 (03-03-2025) Program Scope and Objectives Command Code (CC) Information Returns Processing Online (IRPOL) allows Integrated Data Retrieval System (IDRS) users to request on-line information from the Information Returns Database (IRDB). Audience: These procedures apply to IRS employees who use IDRS system to research information using PAYEE TIN, PAYEE TIN TYPE, PAYER TIN, TAX YEAR and DOCUMENT CODES. Policy Owner: Taxpayer Services (TS) Customer Account Services (SE:W:CAS). Program Owner: Information Returns Master File (IRMF) is a Non-major, high impact planned maintenance project that is part of the Information Returns Processing (IRP) Program. IRMF is categorized as a steady state legacy system that incorporates annual programming changes and legislative changes to maintain functionality. Primary Stakeholders: Stakeholders Impacted by system/application are Taxpayer Services (TS), Small Business/Self-Employed (SBSE),Tax Exempt & Government Entities (TE/GE), Large Business and International (LB&I) Division. Program Goals: This IRM provides the fundamental knowledge and procedural guidance for employees to search various Information Returns Documents by PAYEE TIN, PAYEE TIN TYPE, PAYER TIN, TAX YEAR and DOCUMENT CODES.
Background
2.3.86.1.1 (02-15-2024) Background Information Returns Processing Online (IRPOL) allow tax examiners to research tax payers information to confirm data validity provided to the IRS.
Authority
2.3.86.1.2 (02-15-2024) Authority Command CODE IRPOL was developed to allow users to do research on the IDRS (Integrated Data Retrieval System) for Entity data.
Roles and Responsibilities
2.3.86.1.3 (02-15-2024) Roles and Responsibilities The team manager is responsible for ensuring the program developer receive requirements from stakeholders for annual changes. The programmer is responsible for all changes and updates that are made based on requirements from internal and external stakeholders.
Program Management and Review
2.3.86.1.4 (02-15-2024) Program Management and Review The Program is managed utilizing IRMF Exam Transcripts processing to produce and sort transcript tapes for examination. These tapes will contain taxpayer IRP data which was extracted from IRMF. A Tickler is created for each taxpayer for whom IRP data was extracted from the IRMF. A Standard Transcript Summary report is created with the requested data.
Program Controls
2.3.86.1.5 (02-15-2024) Program Controls IDRS user access code and permissions required to access IRPOL information.
Terms/Acronyms/Definition
2.3.86.1.6 (12-05-2025) Terms/Acronyms/Definition Acronyms Acronym/Term Definition ACA Affordable Care Act CC Command Code DOB Date Of Birth IDRS Integrated Data Retrieval System IRDB Information Returns Database IRM Internal Revenue Manual IRPOL Information Returns Processing Online Legacy A system is designated as legacy if it measurably obstructs IRS mission-critical outcomes by: Limiting functionality essential to key operations or business objectives; Increasing operational risk (e.g., security vulnerabilities, system failures); or Degrading performance (e.g., causing delays or inefficiencies). Legacy status is determined by impact on the IRS' evolving mission requirements, regardless of system age, programming language, or vendor support status. LB&I Large Business and International SB/SE Small Business Self-Employed TE/GE Tax Exempt and Government Entities TIN Taxpayer Identification Number TS Taxpayer Services TY Tax Year
Related Resources
2.3.86.1.7 (02-15-2024) Related Resources IDRS - Integrated Data Retrieval System
Important Dates For Command Code IRPOL
2.3.86.2 (12-05-2025) Important Dates For Command Code IRPOL TY2025 data should be accessible online on Monday, January 5, 2026.
Command Code IRPOL Valid Tax Years
2.3.86.3 (12-05-2025) Command Code IRPOL Valid Tax Years Tax years ( TY2016, TY2017, TY2018, TY2019, TY2020, TY2021, TY2022, TY2023, TY2024, or TY2025) can be referenced in IRPOL currently.
IRPOL Help Screen
2.3.86.4 (09-29-2016) IRPOL Help Screen The figure and table below show the validated fields for the IRPOL Help screen Figure 2.3.86-1 This figure displays the correct setup of the command line to get the IRPOL Help screen. 'IRPOLNNNNNNNNNNVYYYYDD' where NNNNNNNNN is TIN, V is TIN Type and Validity, YYYY is Tax Year and DD is Document Code. Please click here for the text description of the image. 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.
Document Code Availability by Tax Year
Exhibit 2.3.86-1 Document Code Availability by Tax Year Valid Document Codes and available tax years are listed in the table below. DOCUMENT FORM DOC CODE TY2016 TY2017 TY2018 TY2019 TY2020 TY2021 TY2022 TY2023 TY2024 TY2025 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
IRPOLB DOB Search Screen
Exhibit 2.3.86-2 IRPOLB DOB Search Screen IRPOLB DOB Overview screen layout is shown. A line by line description of the screen is explained in the table below. Please click here for the text description of the image. IRPOLB search uses the first and last name, form type, tax year, DOB, state, or zip-code to search for ACA Forms 1095-A, 1095-B, and 1095C. When matching data is found the OVERVIEW Screen will appear. After IRPOLB parameters are entered, the results of the search returns an OVERVIEW screen and a valid IRPOLA command line is displayed. The IRPOLA command line may contain a '00' in the document code position. The '00' must be changed to a valid document code of 07,11,12,56, or 60. To retrieve the form enter the UNIQUE-ID. 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: 2016 thru 2025) 16.1 21 Literal-DOB (YYYY-MM-DD) 18.1 21 Literal-STATE (Use State Abbreviation) 20.1 21 Literal-ZIP CODE 5-DIGITS
IRPOL Overview Screen
Exhibit 2.3.86-3 IRPOL Overview Screen IRPOL Overview screen layout is shown. Line by line description of the screen is explained in the table below. Please click here for the text description of the image. 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 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
Document Display Screen: 1094-B (Doc Code 11)
Exhibit 2.3.86-4 Document Display Screen: 1094-B (Doc Code 11) Form 1094-B Transmittal of Health Coverage Information Returns The display screen layout of Form 1094-B (Doc Code 11) is shown. Line by line description of the screen is explained in the table below. Please click here for the text description of the image. 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.
Document Display Screen: 1094-C (Doc Code 12)
Exhibit 2.3.86-5 Document Display Screen: 1094-C (Doc Code 12) Form 1094-C Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns The display screen layout of Form 1094-C (Doc Code 12) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. Note: In Paper Form Reference column, Box numbers, when they appear, refer to the boxes on the paper forms. 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.
Document Display Screen: 1094-C PART II (Doc Code 12)
Exhibit 2.3.86-6 Document Display Screen: 1094-C PART II (Doc Code 12) Form 1094-C PART II Transmittal of Employer-Provided Health Insurance Offer The display screen layout of a 1094-C Part II (Doc Code 12) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. 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
Document Display Screen: 1094-C PART III (Doc Code 12)
Exhibit 2.3.86-7 Document Display Screen: 1094-C PART III (Doc Code 12) Form 1094-C PART III Transmittal of Employer-Provided Health Insurance Offer The display screen layout of a 1094-C Part III (Doc Code 12) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. 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
Document Display Screen: 1094-C PART IV (Doc Code 12)
Exhibit 2.3.86-8 Document Display Screen: 1094-C PART IV (Doc Code 12) Form 1094-C PART IV Transmittal of Employer-Provided Health Insurance Offer The display screen layout of a 1094-C Part IV(Doc Code 12) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. 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
Document Display Screen: 1094-C Data Reconciliation Code (Doc Code 12)
Exhibit 2.3.86-9 Document Display Screen: 1094-C Data Reconciliation Code (Doc Code 12) Form 1094-C Data Reconciliation Code-Transmittal of Employer-Provided Health Insurance Offer. The display screen layout of Form 1094-C (Doc Code 12) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. 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
Document Display Screen: 1095-A (Doc Code 07)
Exhibit 2.3.86-10 Document Display Screen: 1095-A (Doc Code 07) Form 1095-A PART I Health Insurance Marketplace Statement. The display screen layout of Form 1095-A Part I (Doc Code 07) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. 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
Document Display Screen: 1095-A PART II (Doc Code 07)
Exhibit 2.3.86-11 Document Display Screen: 1095-A PART II (Doc Code 07) Form 1095-A PART II Health Insurance Marketplace Statement. The display screen layout of Form 1095-A Part II (Doc Code 07) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. 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
Document Display Screen: 1095-A PART III (Doc Code 07)
Exhibit 2.3.86-12 Document Display Screen: 1095-A PART III (Doc Code 07) Form 1095-A PART III Health Insurance Marketplace Statement The display screen layout of Form 1095-A Part III (Doc Code 07) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. 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
Document Display Screen: 1095-B (Doc Code 56)
Exhibit 2.3.86-13 Document Display Screen: 1095-B (Doc Code 56) Form 1095-B Health Coverage (Responsible Individual) The display screen layout of Form 1095-B (Doc Code 56) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. 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, 19.2 19.3 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
Document Display Screen: 1095-B PART II (Doc Code 56)
Exhibit 2.3.86-14 Document Display Screen: 1095-B PART II (Doc Code 56) Form 1095-B Part II Health Coverage (Employee-Sponsored Coverage) The display screen layout of Form 1095-B Part II (Doc Code 56) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. 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
Document Display Screen: 1095-C (Doc Code 60)
Exhibit 2.3.86-15 Document Display Screen: 1095-C (Doc Code 60) Form 1095-C Employer-Provided Health Insurance Offer and Coverage The display screen layout of Form 1095-C (Doc Code 60) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. 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
Document Display Screen: 1095-C PART II (Doc Code 60)
Exhibit 2.3.86-16 Document Display Screen: 1095-C PART II (Doc Code 60) Form 1095-C Part II Employer-Provided Health Insurance Offer and Coverage The display screen layout of Form 1095-C Part II (Doc Code 60) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. 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 10.1 Thru 22.1 18 OFFER COVERAGE See Form 1095-C Part II Line 14 Instructions 10.2 Thru 22.2 36 *LOWEST COST See Form 1095-C Part II Line 15 Instructions 10.2 Thru 22.2 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
Document Display Screen: 1095-C Part III (Doc Code 60)
Exhibit 2.3.86-17 Document Display Screen: 1095-C Part III (Doc Code 60) Form 1095-C Part III Employer-Provided Health Insurance Offer and Coverage The display screen layout of Form 1095-C Part III (Doc Code 60) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. 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
Document Display Screen: 1095-C Data Reconciliation Code (Doc Code 60)
Exhibit 2.3.86-18 Document Display Screen: 1095-C Data Reconciliation Code (Doc Code 60) Form 1095-C Data Reconciliation Code- Employer-Provided Health Insurance Offer and Coverage The display screen layout of Form 1095-C (Doc Code 60) is shown. Line by line description of the screen is explained in the table below Please click here for the text description of the image. 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
Source: official text