﻿Form 1094-B
Transmittal of Health Coverage Information Returns
Rev. 2025
Cat. No. 67575A
OMB No. 1545-2252

110116

2025
Department of the Treasury
Internal Revenue Service

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For Official Use Only ----

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 ----

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 ----

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