Federal housing law
Form 1094-C — Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns
Federal housing law as enacted — verbatim and citable.
- Edition
- 2026-10-03
- Last updated
- 2026-10-04
- Jurisdiction
- United States
Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f1094c.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).
120118
18 Total number of Forms 1095-C submitted with this transmittal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19 Is this the authoritative transmittal for this ALE Member? If “Yes,” check the box and continue. If “No,” see instructions . . . . . . . . . . . . . . . .
Part II ALE Member Information
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. Reserved C. Reserved 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. Cat. No. 61571A Form 1094-C (2025) Created 5/21/25
120218
Form 1094-C (2025) Page 2 Part III ALE Member Information—Monthly
| (a) Minimum Essential Coverage Offer Indicator |
(b) Section 4980H Full-Time Employee Count for ALE Member |
(c) Total Employee Count for ALE Member |
(d) Aggregated Group Indicator |
(e) Reserved | ||
|---|---|---|---|---|---|---|
| Yes |
No |
No |
No |
No |
No |
|
| 23 All 12 Months |
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| 24 Jan |
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| 25 Feb |
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| 26 Mar |
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| 27 Apr |
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| 28 May |
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| 29 June |
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| 30 July |
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| 31 Aug |
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| 32 Sept |
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| 33 Oct |
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| 34 Nov |
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| 35 Dec |
Form 1094-C (2025)
120316
Form 1094-C (2025) Page 3 Part IV Other ALE Members of Aggregated ALE Group
Enter the names and EINs of Other ALE Members of the Aggregated ALE Group (who were members at any time during the calendar year).
| Name | EIN | Name | EIN |
|---|---|---|---|
| 36 | 51 | ||
| 37 | 52 | ||
| 38 | 53 | ||
| 39 | 54 | ||
| 40 | 55 | ||
| 41 | 56 | ||
| 42 | 57 | ||
| 43 | 58 | ||
| 44 | 59 | ||
| 45 | 60 | ||
| 46 | 61 | ||
| 47 | 62 | ||
| 48 | 63 | ||
| 49 | 64 | ||
| 50 | 65 |
Form 1094-C (2025)