120118

                                                                                                                                                                               OMB No. 1545-2251
                                  Transmittal of Employer-Provided Health Insurance Offer and                                                               CORRECTED
Form1094-C
Department of the Treasury                                      Coverage Information Returns
Internal Revenue Service                          ▶ Go to www.irs.gov/Form1094C for instructions and the latest information.                                                   2021
Part I  Applicable Large Employer Member (ALE Member)
1   Name of ALE Member (Employer)                                                                                 2 Employer identification number (EIN)

3   Street address (including room or suite no.)

4   City or town                                                                5 State or province               6 Country and ZIP or foreign postal code

7   Name of person to contact                                                                                     8 Contact telephone number

9   Name of Designated Government Entity (only if applicable)                                                     10 Employer identification number (EIN)

11  Street address (including room or suite no.)
                                                                                                                                                                    For Official Use Only
12  City or town                                                              13 State or province                14 Country and ZIP or foreign postal code

15  Name of person to contact                                                                                     16 Contact telephone number

17  Reserved .   .       .    . . . . .         . . . .       . . . . . .   . .  . . .   . .        . . . . .     .  . . .   . . . .         . .            . .   . . . . .  . . .   . . .

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 (2021)

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Form 1094-C (2021)                                                                                                                                   Page2
Part III    ALE Member Information—Monthly
                       (a) Minimum Essential Coverage           Section 4980H Full-Time (c) Total Employee Count    (d) Aggregated       (e) Reserved
                              Offer Indicator               (b) 
                                                       Employee Count for ALE Member         for ALE Member         Group Indicator 
                          Yes                  No                                                                                        

23   All 12 Months

24          Jan

25          Feb

26          Mar

27          Apr

28          May

29          June

30          July

31          Aug

32          Sept

33          Oct

34          Nov

35          Dec

                                                                                                                                            Form 1094-C (2021)

                                                                                                                                       120316

Form 1094-C (2021)                                                                                                                     Page3
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 (2021)