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Box 3 Address Deliv/StreetBox 7 Box 8  Filer (EIN or SSN)Box 9 Box 11 2Part I

Field Name

Size

Type 

Description

Notes

Part

See Form Filer Common Fields

Filer fields common to all form types.

See Recipient Common Fields

Recipient fields common to all form types.

Record Type1TextRecord Type is a required field and it indicates if a record is the Responsible Individual/Employee. Use E for Employee/Responsible Individual & C for Covered Individual 
Box 1 - 6 Employee
CharacterEmployeeFiler InfoPart IBox 7-13 ALE MEMBER (Employer)CharacterApplicable Large Employer MemberRecipient InfoPart I

Box 1 Name

40Text

Box 1: Name of employee

Part IBox 2 TIN11TIN

Box 2: Social security number (ssn)

Part I
Rcp Account25Character Recipient Account Number 

Last Name/Company40CharacterBox 3: employee address Recipient address line 1Part I

Box 4 City

40Character

Box 4: employee city

 Recipient cityPart I
Box 5 State2CharacterBox 5: employee State or province Recipient US state or Canadian province (Use state abbreviation)Part I
Box 6 Zip10CharacterBox 6: employee zip Recipient US zip or Canadian postal codePart I
Employee last name/Company Name

First Name40CharacterBox 7: Name of employerFiler Name or company namePart IEmployee First name

Rcp TIN11CharacterBox 8: Employer identification number (EIN)TINPart IRecipient Tax ID Number

Address Deliv/Street40CharacterBox 9: Employer street address (including room or suite)Filer address line 1Part I
Box 10 Contact20CharacterBox 10: Contact telephone number Filer contact phone numberPart I
Employee Delivery address

Address Apt/Suite40CharacterEmployee Apartment Suite

City40CharacterBox 13: Employer city Filer cityPart IBox 12 StateEmployee City

State23CharacterBox 14: Employer State Filer US state or Canadian province (Use state abbreviation)Part IBox 13 Zip10CharacterBox 13: Employer Zip Filer US zip or Canadian postal codeEmployee State

Zip15CharacterEmployee Zip

Box 14-16 Employer Offer and Coverage
CharacterEmployer Offer and CoverageRecipient InfoPart II
Box 14 Offer coverage2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)Part II
Box 15 Month Premium12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - DecPart II
Box 16 Safe harbor2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)Part II
Box 17- 34 Covered Individuals
CharacterCovered IndividualsEmployee DependentsPart III
Last Name/Company40CharacterCovered Individual last name
Part III
Middle Initial12CharacterCovered Individual Middle initial
Part III
First Name40CharacterCovered Individual first name
Part III
Suffix2CharacterCovered Individual suffixJr , SrPart III
Name Line 240CharacterCovered Individual name line 2Additional name linePart III
Social Security Number11TINCovered Individual SSN
Part III
Date of Birth10DateCovered Individual DOB (if SSN is not available)MM/DD/YYYY or M/D/YYYYPart III
Covered All 12 Months1CheckboxCovered Individual covered all 12 monthsX / Y / T / 1 = CheckedPart III

January Coverage

1Checkbox

January Coverage

X / Y / T / 1 = CheckedPart III
February Coverage1CheckboxFebruary CoverageX / Y / T / 1 = CheckedPart III
March Coverage1CheckboxMarch CoverageX / Y / T / 1 = CheckedPart III
April Coverage1CheckboxApril CoverageX / Y / T / 1 = CheckedPart III
May Coverage1CheckboxMay CoverageX / Y / T / 1 = CheckedPart III
June Coverage1CheckboxJune CoverageX / Y / T / 1 = CheckedPart III
July Coverage1CheckboxJuly CoverageX / Y / T / 1 = CheckedPart III
August Coverage1CheckboxAugust CoverageX / Y / T / 1 = CheckedPart III
September Coverage1CheckboxSeptember CoverageX / Y / T / 1 = CheckedPart III
October Coverage1CheckboxOctober CoverageX / Y / T / 1 = CheckedPart III
November Coverage1CheckboxNovember CoverageX / Y / T / 1 = CheckedPart III
December Coverage1CheckboxDecember CoverageX / Y / T / 1 = CheckedPart III
See Form Common Fields

Form fields common to all form types.

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