EFTA01222589.pdf

560116 F0.1095-B Health Coverage ❑ VOID OMB No. 1545-2252 Department of the Treasury Internal Revenue Service ► Do not attach to your tax return. Keep for your records. OP Go to wwwirs.gov/Fonn10958 for Instructions and the latest Information. ❑ CORRECTED 2017 Part Responsible Individual 1 Name of responsible individ al 2 Social security number (Sm) or other TN 3 Date of birth (d SSN or other TIN a not avaiable) 4 Street address (including apartment no.) 5 City or tovm 6 State or province 7 Country and ZIP or foreign postal code 9 Reserved 8 Enter letter identifying Origin of the Health Coverage (see instructions for codes): . . . Part II Information About Certain Employer-Sponsored Coverage (see instructions) 10 Employer name 11 Employer identification number (EIN) 12 Street address (including room or suite no.) 13 City or town 14 State or province 18 Country and ZIP or foreign postal code sow Issuer or Other Coverage Provider (see instructions) 18 Name 17 Employer identification number (E1N) 18 Contact telephone number 19 Street address (including room or ante no.) 20 City or town 21 State or province 22 Country and ZIP or foreign postal code Naga Covered Individuals (Enter the information for each covered ind vidual.1_ (a) Name of covered individual(s) (b) SSN or other TIN (c) DOB (f SSN or otter (4) Cowed (e) Months of coverage TIN is not evadable) ell 12 slants Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 23 ❑ 0 0 24 25 26 27 28 For Privacy Act and Paperwork Reduction Act Notice. see separate instructions. F0'1111095 Bpoiz) EFTA01222589  560317 farm 1206-8 pin T) peg. 3 Name of responabki mdwidual Social security nun.er (SW et other TIN Owe ul birth (ifs. w WIN, TIN es not EntadeNN Covered Individuals — Con !ovation Sheet (a) Nam of covered...IN) PN SS,...... T. (cVN.: t t=r r r= fa) Months of coven. Jan Feb Mar Apr May Jun Jul Aug Sap Oct Nov Dec 29 ❑ 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 30 0 0 0 0 0 0 0 0 0 0 0 0 0 31 0 0 0 0 0 0 0 0 0 0 0 0 0 32 0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 aa 0 0 0 0 0 0 0 0 0 0 0 0 0 34 0 0 0 0 0 0 0 0 0 0 0 0 0 36 0 0 0 0 0 0 0 0 0 0 0 0 0 as 0 0 0 0 0 0 0 0 0 0 0 0 0 37 0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 ❑0 as as 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 40 hvm1095-B dolt) EFTA01222590