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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
CharacterEmployeeRecipient infoPart I
Rcp Account25Character Recipient Account Number 

Last Name/Company40CharacterEmployee last name/Company Name

First Name40CharacterEmployee First name

Rcp TIN11TINRecipient Tax ID Number

Address Deliv/Street40CharacterEmployee Delivery address

Address Apt/Suite40CharacterEmployee Apartment Suite

City40CharacterEmployee City

State23CharacterEmployee State

Zip15CharacterEmployee Zip

Box 14-17  Employer Offer and Coverage
CharacterEmployer Offer and CoverageFiler InfoPart II
Emp Age Jan 1st3NumericIf the employee was offered an individual coverage HRA, enter the employee’s age on January 1, 2020Age range 1 to 120Part II
Plan Start Month2NumericEnter the two-digit number (01 through 12) indicating the calendar month during which the plan year begins of the health plan in which the employee is offered coverage(Required Field) If there is no health plan under which coverage is offered to the employee, enter “00.”Part II
All Months Coverage2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)Part II

Jan Offer Coverage

2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)
Feb Offer Coverage2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)
Mar Offer Coverage2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)
Apr Offer Coverage2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)
May Offer Coverage2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)
Jun Offer Coverage2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)
Jul Offer Coverage2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)
Aug Offer Coverage2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)
Sep Offer Coverage2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)
Oct Offer Coverage2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)
Nov Offer Coverage2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)
Dec Offer Coverage2CodeBox 14: Offer of Coverage (enter required code) 1A / 1B / 1C / 1D / 1E / 1F / 1G / 1H / 1J / 1K (All12Months or Jan - Dec)
All Months Premium12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - DecPart II
Jan Emp Cost Share12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - Dec
Feb Emp Cost Share12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - Dec
Mar Emp Cost Share12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - Dec
Apr Emp Cost Share12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - Dec
May Emp Cost Share12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - Dec
Jun Emp Cost Share12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - Dec
Jul Emp Cost Share12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - Dec
Aug Emp Cost Share12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - Dec
Sep Emp Cost Share12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - Dec
Oct Emp Cost Share12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - Dec
Nov Emp Cost Share12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - Dec
Dec Emp Cost Share12AmountBox 15: Employee Share of lowest cost monthly premium....All12Months or Jan - Dec
All Months Safe Hbr2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)Part II
Jan Safe Harbor Code2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)
Feb Safe Harbor Code2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)
Mar Safe Harbor Code2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)
Apr Safe Harbor Code2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)
May Safe Harbor Code2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)
Jun Safe Harbor Code2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)
Jul Safe Harbor Code2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)
Aug Safe Harbor Code2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)
Sep Safe Harbor Code2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)
Oct Safe Harbor Code2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)
Nov Safe Harbor Code2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)
Dec Safe Harbor Code2CodeBox 16: Applicable Section 408H Safe Harbor....2A / 2B / 2C / 2D / 2E / 2F / 2G / 2H / (All12Months or Jan - Dec)
All Months Zip Code 5CodeBox 17: Zip Code Used by employers to determine affordabilityPart II
Jan Zip Code 5CodeBox 17: Zip Code Used by employers to determine affordability
Feb Zip Code 5CodeBox 17: Zip Code Used by employers to determine affordability
Mar Zip Code 5CodeBox 17: Zip Code Used by employers to determine affordability
Apr Zip Code 5CodeBox 17: Zip Code Used by employers to determine affordability
May Zip Code 5CodeBox 17: Zip Code Used by employers to determine affordability
Jun Zip Code 5CodeBox 17: Zip Code Used by employers to determine affordability
Jul Zip Code 5CodeBox 17: Zip Code Used by employers to determine affordability
Aug Zip Code 5CodeBox 17: Zip Code Used by employers to determine affordability
Sep Zip Code 5CodeBox 17: Zip Code Used by employers to determine affordability
Oct Zip Code 5CodeBox 17: Zip Code Used by employers to determine affordability
Nov Zip Code 5CodeBox 17: Zip Code Used by employers to determine affordability
Dec Zip Code 5CodeBox 17: Zip Code Used by employers to determine affordability
Box 17- 34 Covered Individuals
CharacterCovered IndividualsEmployee DependentsPart III
Emp Self Insured Chk1CharacterEmployee Self Insured Checkbox X / Y / T / 1 = Checked
Last Name/Company40CharacterCovered Individual last name
Part IIIMiddle Initial
12CharacterCovered Individual Middle initialPart IIIFirst Name40CharacterCovered Individual first namePart IIISuffix2CharacterCovered Individual suffixJr , Sr
Part III
RCP TIN11TINCovered Individual SSN
Part III
RCP Date of Birth10DateCovered Individual DOB (if SSN is not available)MM/DD/YYYY or M/D/YYYYPart III
Ind All Coverage Chk1CheckboxCovered Individual covered all 12 monthsX / Y / T / 1 = CheckedPart III

Ind Jan Coverage Chk

1Checkbox

January Coverage

X / Y / T / 1 = CheckedPart III
Ind Feb Coverage Chk1CheckboxFebruary CoverageX / Y / T / 1 = CheckedPart III
Ind Mar Coverage Chk1CheckboxMarch CoverageX / Y / T / 1 = CheckedPart III
Ind Apr Coverage Chk1CheckboxApril CoverageX / Y / T / 1 = CheckedPart III
Ind May Coverage Chk1CheckboxMay CoverageX / Y / T / 1 = CheckedPart III
Ind Jun Coverage Chk1CheckboxJune CoverageX / Y / T / 1 = CheckedPart III
Ind Jul Coverage Chk1CheckboxJuly CoverageX / Y / T / 1 = CheckedPart III
Ind Aug Coverage Chk1CheckboxAugust CoverageX / Y / T / 1 = CheckedPart III
Ind Sep Coverage Chk1CheckboxSeptember CoverageX / Y / T / 1 = CheckedPart III
Ind Oct Coverage Chk1CheckboxOctober CoverageX / Y / T / 1 = CheckedPart III
Ind Nov Coverage Chk1CheckboxNovember CoverageX / Y / T / 1 = CheckedPart III
Ind Dec Coverage Chk1CheckboxDecember CoverageX / Y / T / 1 = CheckedPart III
See Form Common Fields

Form fields common to all form types.

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