laser CuT sHeeTs 15 laser CuT sHeeTs 14 enveloPes NOTE: Some programs printed on blank stock may not fit our envelopes. Not guaranteed to work with all inserting/stuffing equipment. Call for samples. mosT enveloPes avaIlaBle as SW19 DW19 SWMR DWMR SWMR DWMR DWJW DW19W Important Tax Return Document Enclosed DWM3 Important Tax Return Document Enclosed DW 387 Important Tax Form Documents Important Tax Return Document Enclosed DW4S DW4DN Important Tax Return Document Enclosed SW42 DWU4 DWJH Important Tax Return Document Enclosed DWW2C DW4MW DW3 Important Tax Return Document Enclosed DW298 Important Tax Return Document Enclosed DWW2G DO NOT STAPLE a Control number For Official Use Only OMB No. 1545-0008 b Kind of Payer (Check one) 941 Military 943 944 CT-1 Hshld. emp. Medicare govt. emp. Kind of Employer (Check one) None apply 501c non-govt. State/local non-501c State/local 501c Federal govt. Third-party sick pay (Check if applicable) c Total number of Forms W-2 d Establishment number e Employer identification number (EIN) f Employer’s name g Employer’s address and ZIP code h Other EIN used this year 1 Wages, tips, other compensation 2 Federal income tax withheld 3 Social security wages 4 Social security tax withheld 5 Medicare wages and tips 6 Medicare tax withheld 7 Social security tips 8 Allocated tips 9 10 Dependent care benefits 11 Nonqualified plans 12a Deferred compensation 12b 13 For third-party sick pay use only 14 Income tax withheld by payer of third-party sick pay 15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax Employer's contact person Employer's telephone number For Official Use Only Employer's fax number Employer's email address Under penalties of perjury, I declare that I have examined this return and accompanying documents and, to the best of my knowledge and belief, they are true, correct, and complete. Signature Title Date Form Transmittal of Wage and Tax Statements Department of the Treasury Internal Revenue Service 5200 LW3 41-0852411 33333 W-3 2018 Send this entire page with the entire Copy A page of Form(s) W-2 to the Social Security Administration (SSA). Photocopies are not acceptable. Do not send Form W-3 if you filed electronically with the SSA. Do not send any payment (cash, checks, money orders, etc.) with Forms W-2 and W-3. Reminder Separate instructions. See the 2015 General Instructions for Forms W-2 and W-3 for information on completing this form. Do not file Form W-3 for Form(s) W-2 that were submitted electronically to the SSA. Purpose of Form A Form W-3 Transmittal is completed only when paper Copy A of Form(s) W-2, Wage and Tax Statement, is being filed. Do not file Form W-3 alone. All paper forms must comply with IRS standards and be machine readable. Photocopies are not acceptable. Use a Form W-3 even if only one paper Form W-2 is being filed. Make sure both the Form W-3 and Form(s) W-2 show the correct tax year and Employer Identification Number (EIN). Make a copy of this form and keep it with Copy D (For Employer) of Form(s) W-2 for your records. The IRS recommends retaining copies of these forms for four years. E-Filing The SSA strongly suggests employers report Form W-3 and Forms W-2 Copy A electronically instead of on paper. The SSA provides two free e-filing options on its Business Services Online (BSO) website: • W-2 Online. Use fill-in forms to create, save, print, and submit up to 50 Forms W-2 at a time to the SSA. • File Upload. Upload wage files to the SSA you have created using payroll or tax software that formats the files according to the SSA’s Specifications for Filing Forms W-2 Electronically (EFW2). W-2 Online fill-in forms or file uploads will be on time if submitted by March 31, 2016. For more information, go to www.socialsecurity.gov/ employer. First time filers, select “Go to Register”; returning filers select “Go To Log In.” When To File Mail Form W-3 with Copy A of Form(s) W-2 by February 29, 2016. Where To File Paper Forms Send this entire page with the entire Copy A page of Form(s) W-2 to: Social Security Administration Data Operations Center Wilkes-Barre, PA 18769-0001 Note. If you use “Certified Mail” to file, change the ZIP code to “18769-0002.” If you use an IRS-approved private delivery service, add “ATTN: W-2 Process, 1150 E. Mountain Dr.” to the address and change the ZIP code to “18702-7997.” See Publication 15 (Circular E), Employer’s Tax Guide, for a list of IRS-approved private delivery services. For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions. MANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKS 6969 41-0852411 L1096 5100 Return this entire page to the Internal Revenue Service. Photocopies are not acceptable. Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief, they are true, correct, and complete. Signature ▶ Title ▶ Date ▶ Instructions Future developments. For the latest information about developments related to Form 1096, such as legislation enacted after it was published, go to www.irs.gov/form1096. Reminder. The only acceptable method of filing the information returns listed on this form in box 6 electronically with the Internal Revenue Service is through the FIRE system. See Pub. 1220. Purpose of form. Use this form to transmit paper Forms 1097, 1098, 1099, 3921, 3922, 5498, and W-2G to the Internal Revenue Service. Caution: If you are required to file 250 or more information returns of any one type, you must file electronically. If you are required to file electronically but fail to do so, and you do not have an approved waiver, you may be subject to a penalty. For more information, see part F in the 2016 General Instructions for Certain Information Returns. Forms 1099-QA and 5498-QA can be filed on paper only, regardless of the number of returns. Who must file. The name, address, and TIN of the filer on this form must be the same as those you enter in the upper left area of Forms 1097, 1098, 1099, 3921, 3922, 5498, or W-2G. A filer is any person or entity who files any of the forms shown in line 6 above. Enter the filer’s name, address (including room, suite, or other unit number), and TIN in the spaces provided on the form. When to file. File Form 1096 as follows. • With Forms 1097, 1098, 1099, 3921, 3922, or W-2G, file by February 28, 2017. Caution: File Form 1099-MISC by January 31, 2017, if you are reporting nonemployee compensation in box 7. Also, check box 7 above. • With Forms 5498, file by May 31, 2017. Where To File Send all information returns filed on paper with Form 1096 to the following. If your principal business, office or agency, or legal residence in the case of an individual, is located in Use the following three-line address Alabama, Arizona, Arkansas, Connecticut, Delaware, Florida, Georgia, Kentucky, Louisiana, Maine, Massachusetts, Mississippi, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Texas, Vermont, Virginia, West Virginia Department of the Treasury Internal Revenue Service Center Austin, TX 73301 For more information and the Privacy Act and Paperwork Reduction Act Notice, see the 2016 General Instructions for Certain Information Returns. Form 1096 (2016) DETACH BEFORE MAILING Do Not Staple Form 1096 Department of the Treasury Internal Revenue Service Annual Summary and Transmittal of U.S. Information Returns OMB No. 1545-0108 2018 FILER'S name Street address (including room or suite number) City or town, state or province, country, and ZIP or foreign postal code Name of person to contact Telephone number Email address Fax number For Official Use Only 1 Employer identification number 2 Social security number 3 Total number of forms 4 Federal income tax withheld $ 5 Total amount reported with this Form 1096 $ 6 Enter an “X” in only one box below to indicate the type of form being filed. W-2G 32 1097-BTC 50 1098 81 1098-C 78 1098-E 84 1098-Q 74 1098-T 83 1099-A 80 1099-B 79 1099-C 85 1099-CAP 73 1099-DIV 91 1099-G 86 1099-INT 92 1099-K 10 1099-LTC 93 1099-MISC 95 1099-OID 96 1099-PATR 97 1099-Q 31 1099-QA 1A 1099-R 98 1099-S 75 1099-SA 94 3921 25 3922 26 5498 28 5498-ESA 72 5498-QA 2A 5498-SA 27 7 Form 1099-MISC with NEC in box 7, check . . . . . ▶ •• __ __ __ __ 41-1628061 LW3C Department of the Treasury Internal Revenue Service Transmittal of Corrected Wage and Tax Statements W-3c Form Social Security Administration Data Operations Center P.O. Box 3333 Wilkes-Barre, PA 18767-3333 Purpose of Form If you use the U.S. Postal Service, send Forms W-2c and W-3c to the following address: Where To File For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Use this form to transmit Copy A of Form(s) W-2c, Corrected Wage and Tax Statement (Rev. 2-2009). Make a copy of Form W-3c and keep it with Copy D (For Employer) of Forms W-2c for your records. File Form W-3c even if only one Form W-2c is being filed or if those Forms W-2c are being filed only to correct an employee’s name and social security number (SSN), or the employer identification number (EIN). See the separate Instructions for Forms W-2c and W-3c for information on completing this form. File this form and Copy A of Form(s) W-2c with the Social Security Administration as soon as possible after you discover an error on Forms W-2, W-2AS, W-2GU, W-2CM, W-2VI, or W-2c. Provide Copies B, C, and 2 of Form W-2c to your employees as soon as possible. (Rev. 2-2009) If you use a carrier other than the U.S. Postal Service, send Forms W-2c and W-3c to the following address: Social Security Administration Data Operations Center Attn: W-2c Process 1150 E. Mountain Drive Wilkes-Barre, PA 18702-7997 When To File 55555 Under penalties of perjury, I declare that I have examined this return, including accompanying documents, and, to the best of my knowledge and belief, it is true, correct, and complete. Date Title Signature Number of Forms W-2c b e d Employer’s Federal EIN 1 6 2 Allocated tips 7 Advance EIC payments 8 10 9 Wages, tips, other compensation Federal income tax withheld Social security tax withheld Social security wages 12a-d 11 4 3 Medicare wages and tips Social security tips 5 Complete boxes h, i, or j only if incorrect on last form filed. Employer’s name, address, and ZIP code Nonqualified plans Medicare tax withheld Dependent care benefits (Coded items) For Official Use Only Telephone number Fax number ( ) ( ) For Official Use Only OMB No. 1545-0008 16 State wages, tips, etc. 18 Local wages, tips, etc. 17 19 State income tax Local income tax 943 Military 941/941-SS c Kind of Payer Medicare govt. emp. Hshld. emp. CT-1 Third-party sick pay h Employer’s incorrect Federal EIN Total of corrected amounts as shown on enclosed Forms W-2c. Total of amounts previously reported as shown on enclosed Forms W-2c. Total of amounts previously reported as shown on enclosed Forms W-2c. Total of corrected amounts as shown on enclosed Forms W-2c. f Establishment number g Employer’s state ID number i Incorrect establishment number Contact person Email address Explain decreases here: Has an adjustment been made on an employment tax return filed with the Internal Revenue Service? If “Yes,” give date the return was filed Yes No 944/944-SS j Employer’s incorrect state ID number 1 7 Advance EIC payments 9 Wages, tips, other compensation Social security wages 11 3 Medicare wages and tips Social security tips 5 Nonqualified plans 16 State wages, tips, etc. 18 Local wages, tips, etc. 6 2 Allocated tips 8 10 Federal income tax withheld Social security tax withheld 12a-d 4 Medicare tax withheld Dependent care benefits (Coded items) 17 19 State income tax Local income tax 14 Inc. tax W/H by 3rd party sick pay payer 14 Inc. tax W/H by 3rd party sick pay payer DO NOT CUT, FOLD, OR STAPLE Tax year/Form corrected a / W- Form W-9 (Rev. November 2017) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification Go to www.irs.gov/FormW9 for instructions and the latest information. Give Form to the requester. Do not send to the IRS. Print or type. See Specific Instructions on page 3. 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. 2 Business name/disregarded entity name, if different from above 3 one of the following seven boxes. Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/estate P=Partnership) Note: another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that Other (see instructions) 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from FATCA reporting code (if any) (Applies to accounts maintained outside the U.S.) 5 Address (number, street, and apt. or suite no.) See instructions. 6 City, state, and ZIP code Requester’s name and address (optional) 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Social security number – – or Employer identification number – Part II Certification Under penalties of perjury, I certify that: and he Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the no longer subject to backup withholding; and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments provide your correct TIN. See the instructions for Part II, later. Sign Here Signature of U.S. person Date General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form information return with the IRS must obtain your correct taxpayer (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No. 10231X Form W-9 (Rev. 11-2017) 5311 Form 1042-S Department of the Treasury Internal Revenue Service Foreign Person’s U.S. Source Income Subject to Withholding Go to www.irs.gov/Form1042S for instructions and the latest information. 2018 UNIQUE FORM IDENTIFIER AMENDED AMENDMENT NO. OMB No. 1545-0096 Copy A for Internal Revenue Service 1 Income code 2 Gross income 3 Chapter indicator. Enter “3” or “4” 3a Exemption code 3b Tax rate . 4a Exemption code 4b Tax rate . 5 Withholding allowance 6 Net income 7a Federal tax withheld 7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . . 8 Tax withheld by other agents 9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( ) 10 Total withholding credit (combine boxes 7a, 8, and 9) 11 Tax paid by withholding agent (amounts not withheld) (see instructions) 12a Withholding agent's EIN 12b Ch. 3 status code 12c Ch. 4 status code 12d Withholding agent's name 12e 12f Country code 12g 12h Address (number and street) 12i City or town, state or province, country, ZIP or foreign postal code 13a Recipient's name 13b Recipient's country code 13c Address (number and street) 13d City or town, state or province, country, ZIP or foreign postal code 13e Recipient's U.S. TIN, if any 13f Ch. 3 status code 13g Ch. 4 status code 13h Recipient's GIIN 13i number, if any 13j LOB code 13k Recipient's account number 13l Recipient's date of birth (YYYYMMDD) 14a Primary Withholding Agent's Name (if applicable) 14b Primary Withholding Agent's EIN 15 Check if pro-rata basis reporting 15a 15b Ch. 3 status code 15c Ch. 4 status code 15d 15e 15f Country code 15g 15h Address (number and street) 15i City or town, state or province, country, ZIP or foreign postal code 16a Payer's name 16b Payer's TIN 16c Payer's GIIN 16d Ch. 3 status code 16e Ch. 4 status code 17a State income tax withheld 17b Payer's state tax no. 17c Name of state For Privacy Act and Paperwork Reduction Act Notice, see instructions. Form 1042-S (2018) L42A 5320 41-0852411 Form W-2G 2018 Certain Gambling Winnings Copy A For Internal Revenue Service Center Department of the Treasury - Internal Revenue Service File with Form 1096 OMB No. 1545-0238 For Privacy Act and Paperwork Reduction Act Notice, see the 2017 General Instructions for Certain Information Returns. 3232 VOID CORRECTED PAYER’S name, street address, city or town, province or state, country, and ZIP or foreign postal code PAYER'S telephone number WINNER’S name Street address (including apt. no.) City or town, province or state, country, and ZIP or foreign postal code 1 Reportable winnings $ 2 Date won 3 Type of wager 4 Federal income tax withheld $ 5 Transaction 6 Race $ 8 Cashier 10 Window 11 First I.D. 12 Second I.D. 14 State winnings $ 15 State income tax withheld $ 16 Local winnings $ 17 Local income tax withheld $ 18 Name of locality Under penalties of perjury, I declare that, to the best of my knowledge and belief, the name, address, and taxpayer number that I have furnished correctly identify me as the recipient of this payment and any payments from identical wagers, and that no other person is entitled to any part of these payments. Signature ▶ Date ▶ Form W-2G www.irs.gov/w2g Do Not Cut or Separate Forms on This Page – Do Not Cut or Separate Forms on This Page 41-0852411 Form W-2G 2018 Certain Gambling Winnings Copy A For Internal Revenue Service Center Department of the Treasury - Internal Revenue Service File with Form 1096 OMB No. 1545-0238 For Privacy Act and Paperwork Reduction Act Notice, see the 2017 General Instructions for Certain Information Returns. 3232 VOID CORRECTED PAYER’S name, street address, city or town, province or state, country, and ZIP or foreign postal code PAYER'S telephone number WINNER’S name Street address (including apt. no.) City or town, province or state, country, and ZIP or foreign postal code 1 Reportable winnings $ 2 Date won 3 Type of wager 4 Federal income tax withheld $ 5 Transaction 6 Race $ 8 Cashier 10 Window 11 First I.D. 12 Second I.D. 14 State winnings $ 15 State income tax withheld $ 16 Local winnings $ 17 Local income tax withheld $ 18 Name of locality Under penalties of perjury, I declare that, to the best of my knowledge and belief, the name, address, and taxpayer number that I have furnished correctly identify me as the recipient of this payment and any payments from identical wagers, and that no other person is entitled to any part of these payments. Signature ▶ Date ▶ Form W-2G www.irs.gov/w2g 5230 LW2GA 7 9 Winnings from identical wagers 13 7 9 Winnings from identical wagers 13 DWW2G Use Envelope DWW2G 2018 aca Software by complyright item #14035 DWW2C Use Envelope DWW2C SW42 all lasers 50 sHeets/pack – WHere noTeD: bulk packaGinG 500 sHeets/pack DWCL 2018 version not released at time of printing __ __ __ __ 1095B XID #1607 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 Form 1095-B (2015) __ Fold Here Form 1095-B 2018 Department of the Treasury Internal Revenue Service Health Coverage ▶ Information about Form 1095-B and its separate instructions is at www.irs.gov/form1095b. OMB No. 1545-2252 560115 VOID CORRECTED Part I Responsible Individual 1 Name of responsible individual 2 Social security number (SSN) 3 Date of birth (If SSN is not available) 4 Street address (including apartment no.) 5 City or town 6 State or province 7 Country and ZIP or foreign postal code 9 Part II Employer Sponsored Coverage (see instructions) 10 Employer name 11 12 Street address (including room or suite no.) 13 City or town 14 State or province 15 Country and ZIP or foreign postal code Part III Issuer or Other Coverage Provider (see instructions) 16 Name 17 18 Contact telephone number 19 Street address (including room or suite no.) 20 City or town 21 State or province 22 Country and ZIP or foreign postal code Part IV Covered Individuals (Enter the information for each covered individual(s).) (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not available) (d) Covered all 12 months (e) Months of coverage Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 23 24 25 26 27 28 8 Enter letter identifying Origin of the Policy (see instructions for codes): . . . . . . ▶ form # PorTraiT formaT 1095b50 aca – health coverage 1095c50 employer-Provided health insurance offer and coverage 50 forms per pack 1095-b (irS) 1094-b 1115 Form 1094-B 2017 Transmittal of Health Coverage Information Returns Department of the Treasury Internal Revenue Service Information about Form 1094-B and its separate instructions is at www.irs.gov/form1094b. OMB No. 1545-2252 1 Filer's name 2 Employer identification number (EIN) 3 Name of person to contact 4 Contact telephone number 5 Street address (including room or suite no.) 6 City or town 7 State or province 8 Country and ZIP or foreign postal code 9 Total number of Forms 1095-B submitted with this transmittal . . . . . . . . . . . . . . For Official Use Only Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief, they are true, correct and complete. Signature Title Date For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 Form 1094-B (2014) 1115 Form 1094-B 2017 Transmittal of Health Coverage Information Returns Department of the Treasury Internal Revenue Service Information about Form 1094-B and its separate instructions is at www.irs.gov/form1094b. OMB No. 1545-2252 1 Filer's name 2 Employer identification number (EIN) 3 Name of person to contact 4 Contact telephone number 5 Street address (including room or suite no.) 6 City or town 7 State or province 8 Country and ZIP or foreign postal code 9 Total number of Forms 1095-B submitted with this transmittal . . . . . . . . . . . . . . For Official Use Only Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief, they are true, correct and complete. Signature Title Date For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 Form 1094-B (2014) 120115 CORRECTED Form1094-C Department of the Treasury Internal Revenue Service Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns Information about Form 1094-C and its separate instructions is at www.irs.gov/f1094c. OMB No. 1545-2251 2017 Part I Applicable Large Employer Member (ALE Member) 1 Name of ALE Member (Employer) 2 Employer identification number (EIN) 3 Street address (including room or suite no.) 4 City or town 5 State or province 6 Country and ZIP or foreign postal code 7 Name of person to contact 8 Contact telephone number 9 Name of Designated Government Entity (only if applicable) 10 Employer identification number (EIN) 11 Street address (including room or suite no.) 12 City or town 13 State or province 14 Country and ZIP or foreign postal code 15 Name of person to contact 16 Contact telephone number For Official Use Only 17 Reserved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Total number of Forms 1095-C submitted with this transmittal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Part II ALE Member Information 19 Is this the authoritative transmittal for this ALE Member? If “Yes,” check the box and continue. If “No,” see instructions . . . . . . . . . . . . . . . . 20 Total number of Forms 1095-C filed by and/or on behalf of ALE Member . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Is ALE Member a member of an Aggregated ALE Group? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No If “No,” do not complete Part IV. 22 Certifications of Eligibility (select all that apply): A. Qualifying Offer Method B. Qualifying Offer Method Transition Relief C. Section 4980H Transition Relief D. 98% Offer Method Under penalties of perjury, I declare that I have examined this return and accompanying documents, and to the best of my knowledge and belief, they are true, correct, and complete. Signature Title Date For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 Form 1094-C (2014) __ __ __ __ 1095C 600115 VOID CORRECTED Form 1095-C Department of the Treasury Internal Revenue Service Employer-Provided Health Insurance Offer and Coverage ▶ Information about Form 1095-C and its separate instructions is at www.irs.gov/f1095c. OMB No. 1545-2251 2018 Part I Employee 1 2 Social security number (SSN) Name of employee, street address, city or town, state or province, country, and ZIP or foreign postal code Applicable Large Employer Member (Employer) 7 Name of employer, street address, city or town, state or province, country, and ZIP or foreign postal code 8 Employer identification number (EIN) 10 Contact telephone number Part II Employee Offer and Coverage All 12 Months Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 14 Offer of Coverage (enter required code) 15 Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage $ $ $ $ $ $ $ $ $ $ $ $ $ 16 Applicable Section 4980H Safe Harbor (enter code, if applicable) Part III Covered Individuals If Employer provided self-insured coverage, check the box and enter the information for each covered individual. (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not available) (d) Covered all 12 months (e) Months of Coverage Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 17 18 19 20 21 22 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 Form 1095-C (2015) __ Employer Name Employer Address Line 1 Employer Address Line 2 Employer Address Line 3 Policy Holder Name Policy Holder Address Line 1 Policy Holder Address Line 2 Policy Holder Address Line 3 laser mIsCellaneous forms LaSer w-3 LaSer 1096 LaSer 1042S LaSer w-2c 1095-b LaSer w-3c 1095-c 1095-c (irS) LaSer w-9 form # form # 50’S 500’S Lw3 Lw3500 laser W-3 transmittal form # form # 50’S 500’S L1096 L1096500 laser 1096 transmittal form # L42a18 1042s reciPient coPy a L42b18 1042s reciPient coPy b L42c18 1042s reciPient coPy c L42D18 1042s reciPient coPy d L42e18 1042s WithholdinG aGent coPy e form # oPen DaTe heaDing Lw2ca federal coPy a Lw2cb emPloyee coPy b Lw2cc emPloyee coPy c Lw2c2 emPloyee coPy 2 Lw2cD1 emPloyer / state coPy 1/d 95219e W2c 6Pt. set form # Lw3c laser transmittal for W-2c form # Lw9 laser for W-9 1042S Transmittal available online at IrS.gov LaSer w-2g __ __ __ __ 1095B Form 1095-B 2018 Department of the Treasury Internal Revenue Service Health Coverage ▶ Information about Form 1095-B and its separate instructions is at www.irs.gov/form1095b. OMB No. 1545-2252 560115 VOID CORRECTED Part I Responsible Individual (Policy Holder) 1 Name of responsible individual, street address, city or town, state or province, country, and ZIP or foreign postal code 2 Social security number (SSN) 3 Date of birth (If SSN is not available) 9 Small Business Health Options Program (SHOP) Marketplace identifier, if applicable Part II Employer Sponsored Coverage (If Line 8 is A or B, complete this part.) 10 Employer name, street address, city or town, state or province, country, and ZIP or foreign postal code 11 Employer identification number (EIN) Part III Issuer or Other Coverage Provider 16 Name, street address, city or town, state or province, country, and ZIP or foreign postal code 17 Employer identification number (EIN) 18 Contact telephone number Part IV Covered Individuals (Enter the information for each covered individual(s).) (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not available) (d) Covered all 12 months (e) Months of coverage Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 23 24 25 26 27 28 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 Form 1095-B (2015) 8 Enter letter identifying Origin of the Policy (see instructions for codes): . . . . . . ▶ __ Employer Name Employer Address Line 1 Employer Address Line 2 Employer Address Line 3 Policy Holder Name Policy Holder Address Line 1 Policy Holder Address Line 2 Policy Holder Address Line 3 form # Lw2ga18 laser W-2 G coPy a Lw2gb18 laser W-2 G coPy b Lw2gc218 laser W-2 G coPy c, 2 Lw2gD18 laser W-2 G coPy d, 1 available Self Seal Self DWMrS available Self Seal Self DWMrS SWMR DWMR Use Envelope DWMr SWMR DWMR Use Envelope DWMr 1094-c __ __ __ __ __ __ __ __ __ __ __ __ XID #1607 For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. 41-0852411 Form 1095-C (2015) 1095CIRS 600116 VOID CORRECTED Form 1095-C Department of the Treasury Internal Revenue Service Employer-Provided Health Insurance Offer and Coverage ▶ Information about Form 1095-C and its separate instructions is at www.irs.gov/form1095c OMB No. 1545-2251 2018 Part I Employee 1 Name of employee 2 Social security number (SSN) 3 Street address (including apartment no.) 4 City or town 5 State or province 6 Country and ZIP or foreign postal code Applicable Large Employer Member (Employer) 7 Name of employer 8 9 Street address (including room or suite no.) 10 Contact telephone number 11 City or town 12 State or province 13 Country and ZIP or foreign postal code Part II Employee Offer and Coverage Plan Start Month (Enter 2-digit number): All 12 Months Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 14 Offer of Coverage (enter required code) 15 Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage $ $ $ $ $ $ $ $ $ $ $ $ $ 16 Applicable Section 4980H Safe Harbor (enter code, if applicable) Part III Covered Individuals If Employer provided self-insured coverage, check the box and enter the information for each covered individual. (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not available) (d) Covered all 12 months (e) Months of Coverage Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 17 18 19 20 21 22 2018 Version not released at time of printing 2018 Version not released at time of printing 2018 Version not released at time of printing 2018 Version not released at time of printing form # irS LanDScaPe formaT 1095birS50 aca – health coverage 1095cirS50 employer-Provided health insurance offer and coverage 50 forms per pack. No envelope available for this format. form # PreSSure SeaL PS1095b500 form 1095b health coverage 14" Pressure seal ez fold PS1095c500 employer-Provided health insurance offer and coverage 14" Pressure seal ez fold PS1095bc500bLk form 1095b and/or 1095c blank with dual backers 8½" x 14" Pressure seal ez fold 500 forms per pack form # 1094bT50 transmittal of health coverage information returns 1094cT50 transmittal of employer- Provided health insurance offer and coverage returns 50 forms per pack Use Envelope SW42 DeScriPTion Shown beLow Tax form enveloPes DOUBLE WINDOW & SINGLE WINDOW ENVELOPES FOr W-2’S, 1099’S, 1098’S AND 5498’S Env. Size 5-5/8 x 9-1/4 Top Window Size 15/16 x 4 Btm. Window Size 1-5/16 x 4 Top Position 5/8 from left 3-3/8 from bottom Btm. Position 5/8 from left 1-5/8 from bottom Env. Size 3-7/8 x 8-3/8 Top Window Size 7/8 x 3-3/8 Btm. Window Size 1-1/16 x 3-3/8 Top Position 1/2 from left 2-1/4 from bottom Btm. Position 1/2 from left 11/16 from bottom Env. Size 3-7/8 x 8-7/8 Top Window Size 3-3/8 x 1-1/8 Btm. Window Size 3-3/8 x 1-5/8 Top Position 1/2 from left 3-3/4 from bottom Btm. Position 1/2 from left 1-11/16 from bottom Env. Size 5-7/8 x 9 Top Window Size 2-1/2 x 9/16 Btm. Window Size 2-1/2 x 9/16 Top Position 7/8 from left 3-5/8 from bottom Btm. Position 3 from left 1-7/16 from bottom Env. Size 5-5/8 x 9 Top Window Size 3-7/8 x 5/8 Btm. Window Size 3-7/8 x 11/16 Top Position 5/8 from left 3-1/4 from bottom Btm. Position 4-3/8 from left 1-1/8 from bottom Env. Size 3-7/8 x 8 1/2 Top Window Size 3-1/4 x 7/8 Btm. Window Size 3-1/4 x 13/16 Top Position 3/8 from left 2-7/32 from bottom Btm. Position 3/8 from left 1 from bottom Env. Size 5-5/8 x 9 Top Window Size 3-5/8 x 5/8 Btm. Window Size 3-5/8 x 11/16 Top Position 5/8 from left 3-9/16 from bottom Btm. Position 4-3/8 from left 1-5/16 from bottom Env. Size 3-7/8 x 9 Btm. Position 1/2 from left 1 3/16 from bottom Env. Size 5 5/8 x 9 Top Window Size 1-5/16 x 3-3/4 Btm. Window Size 7/8 x 3-11/16 Top Position 1/2 from left 2-3/4 from bottom Btm. Position 4-1/4 from left 1 7/16 from bottom w-2 Laser and continuous Env# DWCL 1099, 1098T, 5498eSa, 5498Sa, Lr3, 3921, 3922 Env# DW19, SW19 w-2 Laser L4uPw 1099r-Laser Lr4 Env# DW4MW/D w-2 Laser L3uP Env# DW3 LJhi, LJh2, LJh3 Env# DWJH w-2 Laser L275 Env# DW298 1042 Env# SW42 w-2c Env# DWW2C w-2g Env# DWW2G Lu4 Env# DWU4 Env. Size 3-7/8 x 9 Top Window Size 7/8 x 3-5/8 Btm. Window Size 1-9/16 x 3-5/8 Top Position 1/2 from left 2-3/8 from bottom Btm. Position 1/2 from left 1/2 from bottom We can supply DOUBLE WINDOW ENVELOPES to accommodate all preprinted W-2 and 1099 forms which eliminates the need for corner card imprinting. As always, single window with corner card imprinting is available. All window envelopes are white-wove 24lb. paper and are tinted inside for 100% preprinted confidentiality. Our envelopes will accommodate all of the W-2 forms, 1099 forms and laser cut sheets in this catalog. envelopes with Latex adhesive available where noted. Env. Size 3-7/8 x 8-7/8 Top Window Size 1 x 3-7/16 Btm. Window Size 1-1/8 x 3-7/16 Top Position 1/2 from left 2-3/8 from bottom Btm. Position 1/2 from left 1/2 from bottom Important Tax Return Document Enclosed LJb500 Env# DWJW Env. Size 3-7/8 x 8-7/8 Top Window Size 7/8 x 3-3/8 Btm. Window Size 1-1/16 x 3-3/8 Top Position 1/2 from left, 2-1/4 from bottom Btm. Position 1/2 from left, 11/16 from bottom 1099, 1098T, 5498eSa, 3921, 3922, 5498Sa, Lr3 Env# DW19W Self Seal Self Env# DW19WS Env. Size 3-7/8 x 8 7/8 Top Window Size 15/16 x 3-3/8 Btm. Window Size 13/16 x 3-3/8 Top Position 7/16 from left, 2-1/4 from bottom Btm. Position 7/16 from left, 3/4 from bottom Lm3, Lm3bL Env# DWM3 Env. Size 5-5/8 x 9 Top Window Size 3-3/8 x 3/4 Btm. Window Size 3-3/8 x 3/4 Top Position 3/8 from left 4-1/4 from bottom Btm. Position 3/8 from left 5/8 from bottom w-2 Laser L87 Env# DW387 Self Seal Self Env# DW387S Self Seal Self Env# DW4MWS Self Seal Self Env# DW3S Self Seal Self Form# DWCLS Env. Size 5-5/8 x 9 Top Window Size 5/8 x 3-7/8 Btm. Window Size 3/4 x 3-7/8 Top Position 5/16 from left 3-9/16 from bottom Btm. Position 4-1/2 from left 2-1/2 from bottom w-2 Laser 4uP Env# DW4S/D Self Seal Self Form# DW4SS Self Seal Self Form# DW4DNS Important Tax Return Document Enclosed Env. Size 5-5/8 x 9 Top Window Size 3-3/4 x 3/4 Btm. Window Size 3-3/4 x 3/4 Top Position 5/16 from left 4-3/16 from bottom Btm. Position 5/16 from left 11/16 from bottom w-2 Laser L4Dn Env# DW4DN Env. Size 5-5/8 x 9 Top Window Size 3-3/8 x 1-1/8 Btm. Window Size 3-3/8 x 1-7/16 Top Position 1/2 from left 3-3/4 from bottom Btm. Position 1/2 from left 1-1/2 from bottom 1098, 1098c, 1099r, 1099b, 1099Div, 1099inT, 1099k, 1099miSc, 5498, aca Portrait format Env# DWMr, SWMr Self Seal Self Env# DWMrS Important Tax Return Document Enclosed Self Seal Self Env# DW19S Self Seal Self Env# DWU4S Important Tax Return Document Enclosed Self Seal Self Form# DWJHS Important Tax Return Document Enclosed Important Tax Return Document Enclosed Important Tax Return Document Enclosed Important Tax Return Document Enclosed Important Tax Return Document Enclosed * * * * * To view images go to www.taxformfinder.com *Envelope is available in diagonal seam Important Tax Return Document Enclosed May Department of the Treasury Internal Revenue Service 1 Filer's name Name of person to contact Street address (including room or suite no.) Total number of Forms 1095-B submitted with this transmittal Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowl For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Street address (including room or suite no. Simplify your customers’ filing process. Add software to your order! Available as PrePackaged Set with Envelopes