Part III Issuer or Other Coverage Provider

The 9-digits EIN of the provider of the coverage.

The telephone number, including area code, of the provider of the coverage. The complete mailing address of the provider of the coverage. IRS XML schema provides a choice between using US Address or Foreign Address. Differences are noted in individual fields on the right. If TransmitterForeignEntityInd is true then ForeignAddressGrp will be used. Choice between CountryCd and CountryNm

HealthCoverageOriginCd

SponsoringEmployerInfoGrp BusinessName BusinessNameLine1Txt BusinessNameLine2Txt

EIN

MailingAddressGrp USAddressGrp AddressLine1Txt AddressLine2Txt CityNm USStateCd USZIPCd USZIPExtensionCd Or ForeignAddressGrp AddressLine1Txt AddressLine2Txt CityNm CountryCd - OR CountryNm ForeignProvinceNm ForeignPostalCd

IssuerInfoGrp BusinessName BusinessNameLine1Txt BusinessNameLine2Txt

EIN

ContactPhoneNum

Name of the provider of the 16 Name coverage.

Employer Identification 17 number (EIN)

18 Contact telephone number

The 9-digits EIN of the provider of the coverage.

The telephone number, including area code, of the provider of the coverage

Guide for Electronically Filing ACA Information Returns for Software Developers and Transmitters 95

Data Mapping for ISS-UI Services/ISS-A2A Web Services

Form Line 1095-B Data Element Definition XML Element Name Num

MailingAddressGrp USAddressGrp AddressLine1Txt AddressLine2Txt CityNm USStateCd USZIPCd USZIPExtensionCd Or ForeignAddressGrp AddressLine1Txt AddressLine2Txt CityNm CountryCd - OR CountryNm ForeignProvinceNm ForeignPostalCd

Street Address (Including 19 room or suite no.)

20 City or Town

21 State or province

Country and ZIP or Foreign 23 Postal Code

The complete mailing address of the provider of the coverage. IRS XML schema provides a choice between using US Address or Foreign Address. Differences are noted in individual fields on the right. If TransmitterForeign EntityInd is true then ForeignAddressGrp will be used. Choice between CountryCd and CountryNm