Internal Revenue Manual § 3.41.267 - Affordable Care Act Information Return Processing on Service Center Recognition/image Processing System

Section 267 - Affordable Care Act Information Return Processing on Service Center Recognition/image Processing System

3.41.267 Affordable Care Act Information Return Processing on Service Center Recognition/Image Processing System

Manual Transmittal

September 03, 2025

Purpose

(1) This transmits revised IRM 3.41.267, Optical Character Recognition Scanning Operations, Affordable Care Act Information Return Processing on Service Center Recognition/Image Processing System.

Material Changes

(1) Editorial corrections made throughout the IRM as follows:

  • Updated processing valid tax years to 2022 through 2025.

  • Updated delinquent return date ranges for the new processing year to 2026.

  • Updated Naked links.

Effect on Other Documents

This supersedes IRM 3.41.267 dated December 04, 2024 (effective January 01, 2025).

Audience

Taxpayer Services, Submission Processing, Data Conversion Operations

Effective Date

(01-01-2026)

James L. Fish
Director, Submission Processing
Taxpayer Services

3.41.267.1 (01-01-2020)

Program Scope and Objectives

  1. This program provides human intervention for data verification of electronic data record created by optical recognition engines for the purpose of data capture from paper returns filed with the IRS.

  2. Purpose: This IRM provides instruction on processing of paper filed Affordable Care Act information returns (ACA IRP) on the Service Center Recognition/Image Processing System (SCRIPS). This instruction converts taxpayer data reported to electronic data records to fulfill the filing requirement.

  3. Audience: Submission Processing Data Conversion Operation personnel including: clerks, peripheral operators, leads and supervisors. These instructions apply to all campuses.

  4. Policy Owner: The Director of Submission Processing.

  5. Program Owner: Mail Management Data Conversion Section, Return Processing Branch (an organization within Submission Processing).

  6. Primary Stakeholders: Service and Enforcement, ACA Implementation, Compliance Strategy and Policy and Small Business/Self Employed (SB/SE), Operations Business Support, and Office of Servicewide Penalties.

  7. Program Goals: Convert processable paper filed Affordable Care Act information documents to electronic data records.

3.41.267.1.1 (01-01-2018)

Background

  1. Filers send paper information returns to IRS to fulfill their filing requirement and provide their taxpayer identification number (TIN). The IRS must convert the information present on the paper filings to an electronic data record. Employees input and validate the data present and IRS systems for these records during conversion to electronic data records.

3.41.267.1.2 (01-01-2022)

Authority

  1. Authority for these procedures located in Title 26 of the United States Code (USC) or more commonly known as the Internal Revenue Code (IRC). The IRC receives amendments by acts, public laws, treasury determinations, rules, and regulations such as the following:

    • Information Reporting on Health Coverage by Insurers IRC 6055

    • Information Reporting on Health Coverage by Employers IRC 6056

    • Failure to File a Correct Information Return IRC 6721

  2. Policy Statements for Submission Processing located in IRM 1.2.1.4, Policy Statements for Submission Processing Activities.

3.41.267.1.3 (01-01-2018)

Roles and Responsibilities

  1. The Director, Submission Processing approves and authorizes issuance of this IRM.

  2. The Planning and Analysis staff provides feedback and supports local management to achieve and effectively monitor scheduled goals.

  3. The Operations Manager secures, assigns and provides training to perform the instruction.

  4. The team manager assigns, monitors and controls the workflow to complete the work timely.

  5. The employee applies the instruction to the SCRIPS system to convert paper data to an electronic data record.

3.41.267.1.4 (01-01-2020)

Program Management and Review

  1. Program Reports: Management uses these reports to monitor daily (IPS0698 throughout each workday) and weekly status of the program to completeness.

    • IPS0083, Workstation Operator Statistics Program and Function Summary Report

    • IPS0698, Workflow Status

    • IPS01119, Run Balance Report

    • IPS06440, Throughput Statistics Report

    • PCC 2240, Daily Production Report - Program Sequence

    • PCC 6040, SC WP&C Performance and Cost Report

    • PCC 6240, SC WP&C Program Analysis Report

    • PCB 0440, Daily Workload and Staff Hours Schedule

    • PCB 0540, Weekly Workload and Staffing Schedule

  2. Program Effectiveness: Management measures goals using standard documents per hour reports. Each function must complete inventory prior to the program completion date stated in IRM 3.30.123, Work Planning and Control - Processing Timeliness: Cycles, Criteria, and Critical Dates. Local Management ensures quality products conducting and monitoring quality reviews. Managerial or product review in Data Validation function performed each week on every employee and entered in Embedded Quality for Submission Processing System (EQSP). Managerial and product review supplement the quality review process.

  3. Annual Review: Review the processes included in this manual annually to ensure accuracy and promote consistent tax administration.

3.41.267.1.5 (01-01-2018)

Program Controls

  1. Management uses unit production cards (UPCs) to measure and record activity in each function of this program.

  2. Management can use local reports to establish information to support daily program control. Local reports never replace the established official reports.

3.41.267.1.6 (01-01-2018)

Terms/Acronyms/Definitions

  1. Locate terms and acronyms in this instruction in Exhibit 3.41.267-1, Terms/Acronyms/Definitions.

3.41.267.1.7 (01-01-2022)

Related Resources

  1. The following table lists the IRM primary sources of guidance on the processing of paper filed forms under the Affordable Care Act program.

    IRMTitleGuidance on
    IRM 3.10.5Campus Mail and Work Control - Batch/Block Tracking System (BBTS)utilizing BBTS to drop unit production cards for daily incoming receipts and production
    IRM 3.10.72Campus Mail and Work Control - Receiving, Extracting, and Sortingreceiving, extracting, sorting, and routing mail within the Submission Processing campuses
    IRM 3.10.8Campus Mail and Work Control, Information Returns Processingfine sorting, correspondence routing and disposition for Information Returns Program
    IRM 3.13.62Campus Document Services - Media Transport and Controlshipping of SCRIPS requests
    IRM 3.41.274Optical Character Recognition Scanning Operations, General Instructions for Processing via Service Center Recognition/Image Processing Systemworkstation functions, workstation keyboard, windows environment and general instruction for entering data from tax returns and related data through SCRIPS
    IRM 3.41.275Optical Character Recognition Scanning Operations, Scanner Operations on Service Center Recognition/Image Processing Systemscanning returns on the SCRIPS scanner
    IRM 10.5.1Privacy and Information Protection - Privacy Policyshipping of SCRIPS requests
    Document 12990Records and Information Management Records Control Schedulestime frame to destroy paper sample after conversion to electronic data records
    Document 13056Shipping Procedures for Personally Identifiable Information (PII)shipping of image SCRIPS requests
    Document 13144Proper PII Shipping Proceduresshipping of SCRIPS image requests
    Training 2335-seriesInstructor’s Corner for Submission Processing - SCRIPScourse material for SCRIPS entry, located at Instructors Corner for Submission Processing SCRIPS
  2. IRMs present on Servicewide Electronic Research Program (SERP) at the following site: Servicewide Electronic Research Program (SERP). Specific instructional links available on the IMF Data Conversion Research Portal located at IMF Data Conversion Research Portal.

  3. IRM 3.13.62, Campus Document Services - Media Transport and Control, or IRM 10.5.1, Privacy and Information Protection - Privacy Policy, provides information on shipping Personally Identifiable Information (PII). This hdocument is located at: Postal and Transport Policy.

3.41.267.2 (01-01-2018)

Introduction

  1. This IRM section describes certain tasks necessary in the processing of Affordable Care Act information returns processing (ACA IRP) filed on paper with the Service Center Recognition/Image Processing System (SCRIPS).

  2. Submit IRM deviations in writing following instructions from IRM 1.11.2.2, Internal Management Documents System - Internal Revenue Manual (IRM) Process, IRM Standards, and elevated through proper channels for executive approval.

  3. The Taxpayer Bill of Rights (TBOR) lists rights that already existed in the tax code, putting them in simple language and grouping them into 10 fundamental rights. Employees are responsible for being familiar with and acting in accord with taxpayer rights. See IRC 7803(a)(3), Execution of Duties in Accord with Taxpayer Rights, and additional information on the Taxpayer Bill of Rights site located at the following location: Taxpayer Bill of Rights.

3.41.267.2.1 (01-01-2025)

Source Documents

  1. The instructions in this section apply only to the form types listed below for tax years 2022 through 2025:

    Affordable Care Act Information Returns Processing (ACA IRP) Form, TitleForm Characteristics
    Form 1094-B, Transmittal of Health Coverage Information Returnstransmitting one or more Form 1095-B, Health Coverage
    Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returnstransmitting one or more Form 1095-C, Employer-Provided Health Insurance Offer and Coverage
    Stand-alone Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns (SA1094C)with an entry in both corrected box (checked) and Part I, Line 19 box (checked)
    Form 1095-B, Health Coveragetransmitted by Form 1094-B, Transmittal of Health Coverage Information Returns
    Form 1095-C, Employer-Provided Health Insurance Offer and Coveragetransmitted by Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns

3.41.267.2.2 (01-01-2018)

Program Codes

  1. Use program code number 44320 for the processing functions of Affordable Care Act information returns instruction in this IRM.

  2. Limit output files to approximately 200,000 data records of each form type ("B" and "C" ) to accommodate the receiving systems limitations.

    Example:

    A valid output file consists of no more than 200,000 data records of form type "B" and 200,000 data records of form type "C."

3.41.267.2.3 (01-01-2022)

How to Use This Internal Revenue Manual (IRM)

  1. Keystroke Combinations:

    • Carets enclose keystroke combinations (e.g., ).

    • A hyphen separates multiple keystroke combinations (e.g., -M). This means hold down the key while pressing the M key.

  2. Terms and Acronyms - Exhibit 3.41.267-1, Terms/Acronyms/Definitions, lists terms and the definitions of terms related directly and indirectly to ACA IRP SCRIPS processing.

  3. QUICK START - Each function (Original Entry Image (OE-Image), Data Validation Image (DV-Image)) begins with QUICK START instructions intended to speed access to a UW. For detailed data entry and validation instructions found in the following narrative, see IRM 3.41.267.9, General Correction Procedures, and the tables and transcription sheet exhibits in the back of this IRM. More general instructions appear in IRM 3.41.274, Optical Character Recognition Scanning Operations, General Instructions for Processing via Service Center Recognition/Image Processing System.

    Reminder:

    Whenever IRM 3.41.274, Optical Character Recognition Scanning Operations, General Instructions for Processing via Service Center Recognition/Image Processing System, and this IRM conflict, follow this IRM.

  4. Tables

    Table LocationTableTable Entries and Use
    Exhibit 3.41.267-1Terms/Acronyms/Definitionsprovides the corresponding definitions for the provided listing of terms and abbreviations used throughout section 267 of chapter 41
    IRM 3.41.267.1.7Related Resourceslists related resources to use in conjunction with the instruction given
    IRM 3.41.267.2.1 (1)Source Documents Form list and form characteristicslists each form name and title and states the characteristics of each form type
    IRM 3.41.267.5 (3)Workstation Operations Specific Key Functionalitylists specific keyboard keys and key combinations with the functionality of each listed
    Exhibit 3.41.267-2States, State Codes, and Zone Improvement Plan (ZIP) Codes Sorted by Statelists ZIP Code ranges sorted by the state
    Exhibit 3.41.267-3States, State Codes, and Zone Improvement Plan (ZIP) Codes Sorted by ZIP Codelists states sorted by the ZIP Code range
    Exhibit 3.41.267-4Zone Improvement Plan (ZIP) Code, City, and State Exceptionslists exceptions to the ZIP Code ranges
    Exhibit 3.41.267-5Alphabetical Listing of Major Cities with Major City Codes and Zone Improvement Plan (ZIP) Codeslists major city codes for use with address entry
    Exhibit 3.41.267-6Affordable Care Act Information Return Transcription Sheetslists screen prompt and instruction by form page for use in the OE and DV functions
    Exhibit 3.41.267-7Valid Characterslist valid characters and describes the characters allowed in fields present on the transcription sheets
  5. Transcription sheets:

    • Exhibit 3.41.267-6, Affordable Care Information Return Transcription Sheets is transcription sheets for use in the OE and DV functions.

    • Separate sheets for each form type and page number with screen prompts, description and instruction of each individual data field present on the documents is available.

    • These sheets provide most of the information needed to process ACA IRP documents on SCRIPS.

3.41.267.3 (01-01-2022)

Affordable Care Act Information Return Processing Document Preparation

  1. Use IRM 3.41.275, Optical Character Recognition Scanning Operations, Scanner Operations on Service Center Recognition/Image Processing System, for instruction on scanning forms into SCRIPS.

  2. Perform perfection on the UW by placing it in the proper succession (order) for scanning.

    Example:

    A Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns, has a blank page 2 and a completed page 2 followed by a page 3. Cover the entire blank page 2 or copy page 1, to make the work scannable for SCRIPS system.

  3. If a condition exists prohibiting scanning of a processable UW, perform OE from paper process on the UW.

    Note:

    Form 1094 (series) return must still undergo image only process for the retention copy.

3.41.267.3.1 (01-01-2026)

Coding of Late-Filed Submissions

  1. Late filed Form 1094-B, Transmittal of Health Coverage Information Returns, and Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns, submissions received from the IRP Sort function with an IRS Received Date stamp require the Delinquent Return Date (IRS received date) and Delinquent Return Indicator information processed.

  2. Delinquent Return Indicator - Located in the "For Official Use Only" area (first box). Do not enter a date if indicator is ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡.

    Delinquent Return IndicatorDefinition of IndicatorDelinquent Return Date
    Assessed ReturnNo date entry
    ≡ ≡ ≡Collection securedNo date entry
    ≡ ≡Examination securedNo date entry
    Suppress notice indicatorNo date entry
    ≡ ≡Prepared by Civil Penalty UnitNo date entry
    ≡ ≡Penalty assessment is automaticDate entry Return date * for tax year 2025≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ * for tax year 2024 ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ * for tax year 2023≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ * for tax year 2022≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡
    blankTimely filed - no dateNo date entry
  3. A Delinquent Return Date, (boxes 2 through 7) is not present on the transmittal (Form 1094 (series) return) AND delinquent return code ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ is not present, AND it has a valid IRS received date stamp, a delinquent return indicator of "≡ ≡" and a valid received date entered in the 2nd, 3rd, 4th, 5th, 6th and 7th "For Official Use Only" boxes. Enter the date in the MMDDYY format from the boxes or the received date stamp. If there is an "≡" entered in the field and no delinquent return date or an invalid delinquent return date is present remove the "≡ ≡ ≡ ≡" .

3.41.267.3.2 (01-01-2022)

Scanner

  1. See scanner operator instruction in IRM 3.41.275, Optical Character Recognition Scanning Operations, Scanner Operations on Service Center Recognition/Image Processing System, for complete scanner operating instructions.

  2. Select manual feed process from the transport console "IRP-ACA" menu to scan hand drop ACA IRP.

    Note:

    The system assumes the first page is a Form 1094 (series) return.

  3. Scan submissions Form 1094 (series) and all associated Form 1095 (series) again one submission at a time.

    Note:

    The scanner does not reject any pages except mechanical rejects.

  4. Press the key to denote the end of the submission and prompts "Start New Batch, or Q to Quit."

  5. Do not scan batches or boxes of work having many missing or invalid Form IDs on the submissions but return to IRP Sort function for correction. See IRM 3.41.267.4.1, Unprocessable UW Conditions, for instruction on defining invalid Form ID.

3.41.267.3.2.1 (06-27-2017)

Scanner Rejects
  1. The scanner prints the reject code "M" (Mixed Document Type) or "X" to the left of the Document Locator Number (DLN) area on any form or page rejection.

  2. A mixed document type submission received from the scanning function is one of the form types listed in IRM 3.41.267.2.1 (1), Source Documents.

  3. Only non-conforming, mixed, invalid document types, or pages within the submission reject.

3.41.267.3.3 (01-01-2016)

Correspondence on Processable Returns

  1. No entry is "valid" for use with this program.

  2. Remove any entry present in the screen input if noticed.

3.41.267.3.4 (01-01-2019)

Post Document Preparation (Doc Prep) Required

  1. Pull and return to the IRP Sort function daily any documents and Units of Work (UWs) SCRIPS cannot resolve listed on the IRP ACA Pull Document/Submission Report. See IRM 3.41.267.12.9, Pull Unit of Work (Submission) Report for information on the report.

  2. Send Integrated Data Retrieval System (IDRS) image requests daily by secure e-mail to the Unit manager of the requesting unit. Use IUUD:IDRS Unit & USR Database located at the following link to retrieve the e-mail addresses: IDRS Unit Samp; USR Database. Use "ESTAB Request" as the subject of the secure e-mail.

    Note:

    An IDRS List Report is available under General Reports in the backend of SCRIPS for use on volumes. Local level can complete more actions or negotiate alternate distribution with requesting organizations barring excessive staff hour usage.

3.41.267.4 (01-01-2016)

Unprocessable Unit-of-Work

  1. Return to the IRP Sort function all unprocessable documents requiring correspondence. The IRP Sort function corresponds with the filer concerning their submission and asks the filer to refile processable documents.

3.41.267.4.1 (01-01-2021)

Unprocessable Unit-of-Work Conditions

  1. Consider the following conditions unprocessable:

    • You cannot determine what the taxpayer data is (foreign language, completely illegible).

    • You cannot determine the type of return.

    • You cannot determine the tax year of the return.

    • Invalid tax year on the Form 1094 series.

      Example:

      SCRIPS does not process tax years equal to the processing year minus five or more.

    • You cannot determine the tax year of the submission.

      Example:

      The tax year on the transmittal and the tax year on all details do not match.

    • When the name of the filer/employer on the transmittal document (Form 1094 (series)) has one or more of the first four characters present illegible, is entirely illegible, or missing and is not available from the first detail record.

      Exception:

      For Form 1094-B, Transmittal of Health Coverage Information Returns, the filer is not available from the first detail record or any of the detail documents.

    • The filer altered box titles.

    • The submission is missing a transmittal (corresponding Form 1094 series return).

    • Form ID is invalid, missing, in the wrong font, or in the wrong location on the submission or part of the submission.

    • Units of work (UW) where 50 percent or more of the TINs (social security numbers (SSNs)) show only the last four-digits of the SSNs (appear redacted).

      Example:

      If the SSN or a part of the SSN present is masked, hidden, represented by asterisk or, incomplete in any way consider it redacted.

    • When any character in the filer or employer Taxpayer Identification Number/Employer Identification Number (EIN) on the transmittal is illegible or is missing and not available on the first detail.

      Exception:

      For Form 1094-B, Transmittal of Health Coverage Information Returns, the filer is not available from the first detail record or any of the detail documents.

    • When the EIN on the transmittal is equal to a repeating number or sequential numbers.

      Example:

      A repeating EIN is 11-1111111, 22-2222222, etc., and a sequential EIN is 12-3456789.

    • The submission is a Form 1094-B, Transmittal of Health Coverage Information Returns, with no corresponding Form 1095-B, Health Coverage, records.

    • The employer EIN on Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns, does not match the employer listed on Form 1095-C, Employer-Provided Health Insurance Offer and Coverage, transmitted and is noticed.

      Caution:

      This does not apply to the "B" series.

    • The submission is a Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns, with no corresponding Form 1095-C, Employer-Provided Health Insurance Offer and Coverage, records "and" the corrected box "and" line 19 both do not contain a mark.

3.41.267.4.2 (01-29-2019)

Unprocessable Unit-of-Work Disposition

  1. Pull unprocessable units-of-work (UW) daily and returned to the IRP Sort unit for taxpayer correspondence or disposition.

  2. A report titled, IRP ACA Pull Document/Submission Report, displays unprocessable UWs. Pull these daily and returned to the IRP Sort unit. See characteristics of the report in IRM 3.41.267.12.8, Pull Unit of Work (Submission) Report.

    Exception:

    PULL IMAGE ONLY and PULL IMAGE ONLY - NO DLN require resolution in SCRIPS.

  3. Tag each condition prior to forwarding to IRP Sort with the reason code given on the pull report for a specific UW to allow the determination of correspondence sent for these unprocessable documents.

    Example:

    The site can choose to create a routing sheet and include pull document reason codes, circle the code for each UW and attach it when returning the unprocessable documents to IRP Sort unit.

3.41.267.5 (01-01-2022)

Workstation Operations

  1. Refer to the IRM 3.41.274, Optical Character Recognition Scanning Operations, General Instructions for Processing via Service Center Recognition/Image Processing System, for a description of the items below and other items:

    • Keyboard Layout

    • Login/Logoff

    • Operator Statistics

    • Post-to-Close

    • Interrupt/Resume

    • Suspend/Resume

    • Status Line

    • Window Prompts

    • Key Functions

  2. Whenever IRM 3.41.274, Optical Character Recognition Scanning Operations, General Instructions for Processing via Service Center Recognition/Image Processing System, and this IRM conflict, follow this IRM.

  3. Each key or key combination description is the functionality while inside SCRIPS and does not apply to keyboard functionality on other programs. Below lists some function key descriptions.

    Function KeyDescription
    Allows you to move the entry field to a different place relative to the area on the scanned image.
    Allows you to go back and review previous documents or previous pages in the unit-of-work.
    Places the cursor in Overstrike Mode. The keyboard is normally in Overstrike Mode; however, removes the keyboard from Overstrike Mode.
    -- -- -Deletes a unit-of-work.
    - and arrow keys (←→↑↓arrows)Allows you to move the image strip when it is not lined up. Holds the position for the current image.
    -DCopies the data from the same field on the previous document.
    ACA IRP: Allows you to move between page 1, page 2 and or page 3(s) of Form 1094-C, Form 1095-B and Form 1095-C.
    ACA IRP: Allows you to move between page 1, page 2 and or page 3(s) of Form 1094-C, Form 1095-B and Form 1095-C.
    -Prints the current screen on the monitor. ### Caution: Release the Print Screen button first and then the shift key. The printing action begins upon the release of the Print Screen keystroke.
    -MEnlarges the size of the scanned image appearing above the entry field.
    -LReduces the size of the scanned image appearing above the entry field.

3.41.267.6 (01-01-2016)

Forms Identification (FI) Function

  1. Non-conforming form is when the scanner does not recognize all documents or all pages of the document. These include photocopies of official documents, official forms but for some reason do not meet the official specifications for measurement, homemade documents of varying formats or documents without or with invalid form identification numbers in the upper right-hand corner of the page. The FI function allows the manager/work leader to identify the form (or the page of the form) to avoid rework at the scanner. The FI screen displays an image and an entry template on the right. The entry template permits the operator to select what form type the image is, or to delete a single image or an entire submission from further processing. The menus shown on the screen depend on how your supervisor profiled you.

    Example:

    The FI option appears grayed out on the Workstation Main Menu if not in your profile.

3.41.267.6.1 (01-01-2022)

Forms Identification (FI) QUICK START

  1. From the Workstation Main Menu, select the numeric code for Original Entry (OE).

  2. From the Original Entry (OE) Selection Menu, select the numeric code for Form Identification Selection Menu.

  3. From the Form Identification Selection Menu, select the numeric code for the type of FI needed.

  4. The first group of images, from a UW requiring identification, opens.

  5. If an incorrect option is selected from the Form Identification Selection Menu, press the -P key combination to set post-to-close and press to suspend, before entering any data, to return to the Form Identification Selection Menu.

    Note:

    Notify your supervisor.

  6. Press the -P post-to-close key combination to end FI after completing the current UW.

  7. The system returns to the Form Identification Selection Menu when you complete the last image identification in the UW.

3.41.267.6.2 (01-01-2025)

Form Identification (FI) Processing

  1. The system assigns a six-digit sequence number instead of a document locator number (DLN) to documents it cannot identify. This number assists in locating the UW when researching documents. Once the form type/page is identified, the system assigns a DLN to the document.

  2. Identify the image by entering the proper number or letter selection from the template in the form identification menu selection. The tables below appear on the SCRIPS workstation directly below each other.

    Form 1094 Series

    Menu OptionForm/Page/(Form ID)Menu OptionForm/Page/(Form ID)
    AForm 1094-B pg1 (110116)BForm 1094-C pg1 (120118)
    CForm 1094-C pg2 (120218)
    DForm 1094-C pg3 (120316)

     

    Form 1095 Series

    Menu OptionForm/Page/(Form ID)Menu OptionForm/Page/(Form ID)
    1Form 1095-B pg1 (560118)3Form 1095-C pg1 (600120)
    4Form 1095-C pg1 (600118) ### Note: Do not use.
    2Form 1095-B pg3 (560318)5Form 1095-C pg3 (600320)
    6Form 1095-C pg3 (600318) ### Note: Do not use.

    Press the key to complete a selection.

  3. Press to suspend the document for the person working suspense to research when you cannot identify the image. If the image is unprocessable, press "X" to remove the document from further processing.

  4. Suspend the document for the supervisor if the image is a form type other than ACA IRP (such as Form 1040 or Form 941) by pressing . The person working suspense pulls the documents for proper routing before pressing "X" to remove the document from further processing.

  5. If multiple form types exist in a submission, research is needed to determine if the submission requires deleting. Deleting the entire submission is sometimes more efficient, than removing many single documents. Delete submissions by pressing the --, -, or -- key combination.

  6. Press the -P post-to-close key combination to set post-to-close to end the session. The system returns you to the Original Entry (OE) Selection Menu when you complete the last image in the UW.

3.41.267.7 (01-01-2016)

Original Entry (OE) Function

  1. Use the OE function to manually key enter data from both scanned images and from paper documents. The menus shown on the screen depends on how your supervisor profiled you.

    Example:

    This option is grayed on the Workstation Main Menu if it is not in your profile.

3.41.267.7.1 (01-01-2022)

Original Entry (OE) Image QUICK START

  1. From the Workstation Main Menu, select Original Entry (OE).

  2. From the Original Entry (OE) Selection Menu, select OE Image Selection Menu.

  3. From the OE Image Selection Menu, select IRP ACA OE Image.

  4. From the IRP ACA OE Image Selection Menu, select one of the following:

    • 1 - All IRP ACA OE Image

    • 2 - Form 1094-B OE Image

    • 3 - Form 1094-C OE Image

  5. After the selection is entered press as prompted or press -X to exit to previous menu.

  6. The first individual document in a UW requiring OE opens. See Exhibit 3.41.267-6, Affordable Care Act Information Return Transcription Sheets.

    1. The scanned image of the document displays on the left side of the workstation screen.

    2. The right side of the workstation screen is where the data is input in the specific field window.

  7. If an incorrect option is selected, press the -P post-to-close key combination and then suspend this UW. Notify your supervisor.

  8. If the last data entered is not the last field of the page and there is no other data present on the page, press key to release a document and display the next template.

  9. Press the -P post-to-close key combination to end OE from Image.

  10. The system returns you to the Original Entry (OE) Selection Menu when you complete the last document in the current UW.

3.41.267.7.2 (01-01-2017)

Original Entry (OE) Image Processing

  1. The Status Line at the bottom of the screen displays the following information:

    1. The program field is 44320 for ACA IRP documents.

    2. The DLN field is the DLN of the document displayed.

    3. The document field is the relative count of the document.

      Example:

      If it is the first document in a unit-of-work with 250 documents, the document field shows a count of 1 of 250.

    4. The Pg. field is the relative count of the page of the document.

      Example:

      If it is Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns, page 1, the Pg field shows 1 of 2 or 1 of 3 depending on the length of the return filed; Form 1094-C page 2 shows as 2 of 2 or 2 of 3 depending on the length of the return filed.

    5. The Status Line is "IN" when the insert mode is on and "NU" when the numeric mode is on.

  2. In OE from Image, you manually enter information into the template using a scanned image of the return as a source.

3.41.267.7.3 (01-01-2022)

Original Entry (OE) From Paper Quick Start

  1. From the Workstation Main Menu, select Original Entry (OE).

  2. From the Original Entry (OE) Selection Menu, select OE Paper Selection Menu.

  3. From the OE Paper Selection Menu, select IRP ACA OE Paper Selection Menu.

  4. From the IRP ACA OE Paper Selection Menu, select the form type:

    • 1 - Form 1094-B OE Paper

    • 2 - Form 1094-C OE Paper

  5. After the selection is entered press as prompted or press -X to exit to previous menu.

  6. If the wrong program is selected and the first page of the first document is not complete, press the key to cancel the entry. You return to the IRP ACA OE Paper Selection Menu.

3.41.267.7.4 (01-01-2019)

Original Entry (OE) From Paper Processing

  1. In OE from Paper, the workstation operators manually enter information into the system and eliminate all transport processing. The operators need the paper IRP ACA units-of-work to perform OE from paper. SCRIPS assigns a DLN for each document entered from paper but does not print them on the documents. As each new IRP ACA document is processed, the system displays the DLN of the document in the DLN field of the Status Line at the bottom right side of the screen.

  2. After selecting the form type from the IRP ACA OE Paper Selection Menu, your first prompt is for the form year, followed by the system reminder window "Enter amounts as DOLLARS ONLY."

  3. A blank Form 1094-X template is displayed for the first document in the block with the Sequence Number field displayed for entry. The first document must begin with sequence number "00."

  4. The Status Line at the bottom of the monitor screen displays the following information:

    1. The Program field shows 44320 for IRP ACA documents.

    2. The DLN field shows the DLN of the current document.

    3. The SUB field shows the relative count of submission work.

    4. The Status Line shows "IN" when the insert mode is on and "NU" when the numeric mode is on.

  5. Write the DLN assigned by the system in the upper right-hand corner of the paper document (either the Form 1094-X or Form 1095-X as determined at the site location). The system assigned DLN is shown in the DLN field of the Status Line.

    Reminder:

    Writing the DLN for the Form 1094-X is necessary so subsequent operators can retrieve the UW.

  6. After entering Pg. 1 (or 2), your next prompt is "Is a page 2 (or 3) present?" Never enter a page without significant taxpayer data, not considered processable, or is a page not data captured such as the instruction pages or duplicate taxpayer forms.

    Exception:

    Form 1094-B, Transmittal of Health Coverage Information Returns, has a Pg 1 ONLY, therefore the system moves straight into a Form 1095-B, Health Coverage, template.

    1. If "Yes," a page 2 (or 3) template is presented.

    2. If "No," you see a prompt "Is next document Form 1095-X?"

      Response Choice IfAction Then
      "Yes"A Form 1095-X is presented asking for a sequence number. ### Note: When entering a Form 1095-X, the different DLN in the Status Line is like a 1099 detail document in regular IRP versus the 1096 DLN.
      "No"Presentation is the next sequence number prompt for the same document type.
  7. After entering all documents press the and keys to end OE from paper or press -P (post-to-close) while entering, but before releasing the last document in the UW. The system returns you to the IRP ACA OE Paper Selection Menu.

3.41.267.7.5 (01-01-2018)

Releasing a Unit-of-Work in Original Entry (OE)

  1. For OE Image, when you release the last document in a UW, this also releases the UW:

    1. If -P is pressed before releasing the UW, the OE Selection Menu opens.

    2. If -P is not pressed, another UW opens.

3.41.267.7.6 (01-01-2022)

Selecting a Specific Unit-of-Work in Original Entry (OE)

  1. A specific ACA IRP unit-of-work is selected for OE by following these steps:

    1. Select the numeric code for Original Entry (OE) from the Workstation Main Menu. The Workstation Main Menu closes, and the Original Entry (OE) Selection Menu opens. The menus shown on the screen depend on how your supervisor profiled you.

    2. Enter the numeric code for OE Select Block from the Original Entry (OE) Selection Menu. The Original Entry (OE) Selection Menu closes, and the Open Block/Unit of Work window opens.

    3. Enter the 14-digit DLN from the Form 1094 (series) return from the Open Block/Unit of Work window.

    4. Press the key. The Open Block/Unit of Work window closes and the selected UW opens. If the block is not available, an error message is displayed indicating the block is not available.

      Example:

      A message is displayed if you previously worked on the block, or if another operator is currently working on the Block/UW.

    5. Enter data using IRM 3.41.267.9, General Correction Procedures, and Exhibit 3.41.267-6, Affordable Care Act Information Return Transcription Sheets, and other instruction in this IRM on the open designated Form 1094 (series) document.

    6. Press the -P post-to-close key combination and then suspend the UW if an incorrect UW is selected for the Open Block/Unit of Work menu then notify your supervisor.

3.41.267.8 (01-01-2018)

Data Validation (DV) Function

  1. The DV function is used to manually correct data from scanned images. The menus shown on the screen depend on how your supervisor profiled you.

    Example:

    This option is grayed on the Workstation Main Menu if it is not in your profile.

  2. The Status Line at the bottom of the screen displays the following information:

    1. The DLN field shows the DLN of the document displayed.

    2. The SUB field shows the relative count of the document.

      Example:

      If it is the first document in a UW with 80 documents, the SUB field shows a count of 1 of 80.

    3. The Pg. field shows the relative count of the page of the document.

      Example:

      If it is Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns, page 1, the Pg. field shows 1 of 3, page 3 shows as 3 of 3.

    4. The Status Line shows "AU" when the automatic mode is on, "IN" when the insert mode is on, and "NU" when the numeric mode is on.

      Note:

      AUTO indicator turns the AUTO mode on and off. When AUTO is on, the cursor automatically moves from the current field to the next field requiring perfection. When AUTO is off, the cursor manually moves through every field using the cursor movement keys. A Select Block or Suspended Block in DV requires the operator to restore the AUTO on mode using --.

3.41.267.8.1 (01-01-2022)

Data Validation (DV) From Image QUICK START

  1. From the Workstation Main Menu, select the numeric code for Data Validation (DV).

  2. From the Data Validation (DV) Selection Menu, select the numeric code for DV Selection Menu.

  3. From the DV Selection Menu, select the numeric code for IRP ACA DV Selection Menu.

  4. From the IRP ACA DV Selection Menu, select the numeric code needed. The menus shown on the screen depend on how your supervisor profiled you.

    • 1 - All IRP ACA DV

    • 2 - Form 1094-B DV

    • 3 - Form 1094-C DV

    • 4 - All Scanned IRP ACA DV2

  5. The first UW opens, and the cursor stops at the first highlighted field when the AUTO is on. Use the exhibits and the general correction procedures in this IRM to apply corrections.

  6. If an incorrect option is selected from the IRP ACA DV Selection Menu before entering any data, press -P post-to-close, press to suspend and return to the DV Selection Menu. Notify supervisor.

  7. After entering the last field on document, if AUTO is off, press the key to release the document and display the next template.

  8. Press the -P post-to-close key combination to stop a new block from appearing once the current UW is completed.

  9. The system returns you to the Data Validation (DV) Selection Menu when you release the last document.

3.41.267.8.2 (01-01-2022)

Selecting a Specific Unit-of-Work in Data Validation (DV)

  1. A specific UW of ACA IRP documents, is selected for DV by following these steps:

    1. From the Workstation Main Menu, select the numeric code for Data Validation (DV). The Workstation Main Menu closes, and the Data Validation (DV) Selection Menu opens. The menus shown on the screen depend on how your supervisor profiled you.

      Example:

      This option does not display on the menu if it is not in your profile.

    2. From the Data Validation (DV) Selection Menu, enter the numeric code for DV Select Block. The Data Validation (DV) Selection Menu closes, and the Open Block/Unit of Work window opens.

    3. Enter the 14-digit DLN from Form 1094 (series) document.

    4. Press the key. The Open Block/Unit of Work window closes and the selected UW opens.

    5. The first document needing correction opens.

    6. Enter data using Exhibit 3.41.267-6, Affordable Care Act Information Return Transcription Sheets, and other exhibits, as needed, in this IRM.

    7. A suspended UW in DV requires the operator to restore the "AUTO ON" mode.

      Reminder:

      If after entering the DLN, the screen goes white for a second and then returns to the menu, the block is technically worked. The system ran through all the system checks resulting in no errors.

    8. If an incorrect UW is selected from the Open Block/Unit of Work menu, press the -P post-to-close key combination and suspend the UW. Notify your supervisor.

  2. Use menu option IRP ACA DV2 Select Block to correct blocks exceeding threshold checks previously entered.

3.41.267.9 (01-01-2022)

General Correction Procedures

  1. Use these procedures as a guide during the Original Entry (OE) and Data Validation (DV) functions. Not all items apply to specific situations in either function. Correction is needed to fields not highlighted if a correction made to a highlighted field creates an error. Sight verify any field with any incorrect characters. If the system stops on a field, sight verify and correct all incorrect items present in the field.

  2. If you reach the maximum field length while entering data, the cursor, in most cases, automatically moves to the next field. Remove or correct incorrect characters inadvertently entered in the next field.

  3. Any checkbox present on any form type requires sight verification if the system reads the box as marked.

  4. The -4 (Override key) is not enabled for field character type, tax year, or invalid date of birth (MMDDYYYY).

    Example:

    Invalid dates: 01321980, 13011980, 00011980, 01020080 or a date before 01011902.

  5. Date of Birth (DOB) fields require entry in MM, DD, YYYY format. When the taxpayer entry YY is present and the century (taxpayer intent) is determined entry the YYYY. An entry missing any of the combination "is not" a DOB. Do not enter any data in the field if you cannot determine all three things.

  6. Error Messages—Messages found in the Prompt Area with information giving helpful hints to correct the error. Most error messages consist of two lines with the first line displaying the error message and the second information to help resolve the error condition.

  7. An asterisk (*) at the upper right-hand corner of the normal proper placement of the numerous check boxes present on the return represent the skip key stop points.

    Caution:

    Taxpayer generated forms may not have the checkbox placement in the correct location. Do not mistake the skip box asterisk for taxpayer entries during OE or DV operations.

  8. While working in OE Image or DV Image, if you cannot determine the data for any field (except the Street Address, City fields) from the image because it is illegible or the image is incomplete, suspend the UW and pull the paper document for verification.

  9. While working in OE Image or DV Image, do not enter data marked out or crossed through by the filer. Do enter data written in or placed on the document in different font.

  10. Press the key to view the entity information from a Form 1094-B, Transmittal of Health Coverage Information Returns, or Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns, while the transmitted form is displayed for reference. It also displays the entity information from the transmitted form while a Form 1094-B, Transmittal of Health Coverage Information Returns, or Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns, is displayed.

  11. In certain situations, the scanner may read a name or address or even a city without spaces or spread over the name line or address fields. If the system read the name and address correctly, leave as is.

    Note:

    If the scanner reads a line correctly but placed the information in an incorrect field, move the information as scanned to the correct entry field using up and down arrows. Moving an address to the correct field does not require updates to standard abbreviations.

  12. The - combination key function provides the operator the ability to access the last edited field or the last flagged field of the previous document.

  13. Taxpayer identification number, social security number or employer identification number fields, presented as 1-xxx-xx-xxxx-0 or 1-xx-xxxxxxx-0, or any variation thereof, is entered as xxxxxxxxx, omitting the leading and ending numeric.

  14. If detail documents (Form 1095 series) presented consecutively have the same responsible individual or employee and the same covered individuals duplicated, enter one document and void the duplicate(s).

  15. For more information on function keys refer to the table in IRM 3.41.267.5 (3), Workstation Operations, or IRM 3.41.274, Optical Character Recognition Scanning Operations, General Instructions for Processing via Service Center Recognition/Image Processing System, Exhibit 3.41.274-1, Function Key Use and Description by Form Type.

  16. Cross field validations occur on certain conditions and require sight validation and verification. Follow the screen prompts to allow systemic determination of the disposition of the UW. See the table below for these conditions.

    Form NumberFieldComparison Field(s)Valid ConditionInvalid Condition(s) Requiring Sight Verification
    Form 1094-CLine 19Part II Part III Part IV1. L19 is blank PII, PIII and PIV is blank. 2. L19 is marked PII, PIII and PIV each has some or all data.1. L19 is blank PII, PIII and PIV each or individually partially or fully populated. 2. L19 is marked PII, PIII and PIV is blank. 3. \>sight verify
    Form 1095-B and Form 1095-C Covered IndividualsSSNDOB1. SSN is present and no DOB is present 2. SSN is not present and a valid DOB is present 3. No SSN is present no DOB is present and no name is present1. Partial SSN is present and no DOB is present 2. SSN is not present and an invalid DOB is present 3. No SSN is present no DOB is present and no name is present 4. \>sight verify
    Form 1095-B and Form 1095-CAll 12 monthsone or more 'month' markedAll 12 months box is checked, and Jan through Dec boxes have no checksAll 12 months box is checked and one or more of Jan through Dec boxes have a check \>sight verify
    Form 1095-BPage 3 SSN and/or DOBPage 1 Line 2 and/or Line 3Entries match data capture continuesEntry mismatch Page 3 is dropped \>sight verify
    Form 1095-C Tax Year 2019Page 3 Employee SSNPage 1 Line 2Entries match data capture continuesEntry mismatch Page 3 is dropped \>sight verify
  17. The system performs threshold validations and places documents in DV2 when 50 percent or more of the SSNs and/or DOBs in the UW appear missing or invalid. This condition requires sight validation and verification. Turn the AUTO off and arrow back to column A under covered individuals to correct erroneously entered name field data. Follow the screen prompts to allow systemic determination of the disposition of the UW. See threshold reason codes at IRM 3.41.267.12.9 (4).

    Note:

    A pop-up notification appears at the beginning of the block, "This submission does not meet threshold validation criteria: Invalid SSN and DOB. It deletes after DV unless the field data is modified." Press "OK" and proceed with sight verification.

3.41.267.9.1 (01-01-2019)

Name and Address Block Reader (NABR)

  1. Name and Address Block Reader is referred to as NABR. NABR is used to improve the accuracy of addresses captured by the scanner from IRP documents. The NABR accomplishes this improvement by comparing the address captured by the scanner with a database of addresses used by the United States Postal Service. SCRIPS uses NABR to run addresses through a Postal Database.

  2. When validating a NABR change, ensure the system read the correct ZIP Code. Correct the data to match the image if the city and state do not match the image and a correct ZIP Code is not present in the data field.

  3. The system prompts an operator to "Please verify" the following conditions:

    • State is determined by the system from the city present

    • State is determined from the ZIP Code present

    • City is updated by the system to a phonetic match

    • City is determined from ZIP Code

    • Acceptable city name used

    Note:

    NABR does not appear in the bottom right-hand corner in the conditions listed above.

3.41.267.9.2 (01-01-2022)

Name Entry

  1. Enter the information as shown on the document, in the provided name line or the first, middle initial, and last name/full name except as instructed below:

    1. If the filer has submitted the same name twice on a form, enter it only once.

    2. Space for a period.

    3. Never enter two consecutive spaces.

    4. If during sight verification a correction is made, or if in OE, enter the first name first and last name last.

    5. Space within a true last name where shown.

    6. Omit apostrophe (') if shown in name line. Do not space for an apostrophe.

    7. Omit slash (/) if shown in name line. Space for a slash.

    8. Enter a hyphen (-) where shown. Do not space before or after the hyphen.

    9. Enter numerics present in the name line.

    10. Enter ampersand "&" when present in the Form 1094 series name line or the Form 1095 series last name/full name line.

    11. Data normally entered on Name line 2, such as; doing business as (DBA), in care of (C/O) or %, or also known as (AKA) is entered/placed behind the business name if a correction requires your intervention.

      Note:

      Do not enter %, DBA or AKA. If scanner reads DBA or TA (Trust Agreement) correctly and no other correction is needed, leave as is.

    12. Omit the designation only such as Trust Agreement (TA), DBA, AKA, Owner, Proprietor when entering data.

      Note:

      Do not enter DBA or TA. If scanner reads DBA or TA correctly and no other correction is needed, leave as is.
      Do not enter the designations or data for: Formerly known as (FKA), formerly DBA or any data after these designations.

  2. Separate the name entered on the form to the first name, middle initial, and last name fields if able to determine the data when the filer does not place the names in the proper fields. Official forms have specific areas for first name, middle initial, and last name. If you cannot determine place the entire name present in the last name field.

  3. Do not enter "No Middle Initial" (NMI), "No Middle Name" (NMN), or "No Last Name."

  4. Always enter suffixes Jr., Sr., or Minor after the last name in the last name field. Omit suffixes such as MD, TP, and SP.

  5. If only a single name appears consider it the last name and enter it in the last name field.

3.41.267.9.3 (01-01-2018)

Address Elements

  1. Enter the information exactly as shown on the document except as instructed below or when the NABR has perfected the address. See IRM 3.41.267.9.1, Name and Address Block Reader (NABR):

    1. Do not enter periods in the address field. However, acceptable punctuation such as slash (/) and hyphen (-) may be entered. If a period is present between two numbers enter a space for the period.

    2. If an ampersand (&) is present in the street address enter as AND.

    3. If an apostrophe (‘) is present omit the apostrophe and do not leave a space for the apostrophe.

    4. If perfecting only part of the address, such as the state or ZIP Code do not go back to the street address to abbreviate or correct characters if the scanner picked up the street address as present on the document.

      Exception:

      If the name of the street is a direction, the direction is spelled out. Do not abbreviate street names.

      Example:

      123 North Street is entered as 123 NORTH ST.

    5. If a document has a street address and a PO Box, enter both on the address line with the PO Box or (*) entered first. If the combination is too long, enter only the PO Box. Also, use abbreviations as necessary to limit this entry to 35 positions. Enter as much of the street address with abbreviations as possible.

    6. When two street addresses with the same city and ZIP appear, enter the first street address. If two addresses appear, including a PO Box and an address, with different city and ZIP Code, enter the first in the address, city, state and ZIP Code fields.

    7. Omit "No, No., Num, #, or Number" if it appears as a prefix to a house, apartment, Route, or PO Box number.

    8. If North, South, East or West is shown as part of the city name, use the standard abbreviation (such as N=North, S=South, etc.). NEVER use a Major City Code and the standard abbreviation together.

      Example:

      West Miami enter as W MIAMI, not W MF.

    9. If the city has numerics, enter as alphas.

      Example:

      29 Palms enter as TWENTY NINE PALMS.

    10. Abbreviate only the last designation present if multiple street designations appear.

      Example:

      1234 Circle Road Drive is entered as: 1234 CIRCLE ROAD DR

    11. If correcting or transcribing an address field add ST, ND, RD or TH to a numbered street when there is a street designation such as Road or Street.

      Note:

      102 S. 38 Road is entered as 102 S 38TH RD

    12. If the street address is not determined or is blank, enter "Z" in the Address field. If the city is not determined or is blank, enter "ZZZ" in the City field and leave the State and ZIP Code fields blank.

    13. Enter standard abbreviations for states and territories as shown in Exhibit 3.41.267-2, States, State Codes, and Zone Improvement Plan (ZIP) Codes Sorted by State, and Exhibit 3.41.267-3, States, State Codes, and Zone Improvement Plan (ZIP) Codes Sorted by ZIP Code.

    14. If there is no state, but a ZIP Code is present, enter the ZIP Code as shown and press . This generates the state code for this ZIP Code in the prompt area. Follow the screen prompt to accept this code or to enter a different code.

    15. If there is no ZIP Code (or the ZIP Code is less than or more than five digits) but a state is present, press the key in the ZIP Code field. The system generates the default ZIP Code for this state.

      Note:

      DO NOT generate the default ZIP Code without first entering the ZIP Code "if" present on the form.

    16. If the system finds the ZIP Code entered and present on the form does not match the state code present, the system asks, "Is this a foreign address?" If the answer is "Yes" the system continues by presenting fields for a foreign address entry, Province (17 characters), Foreign postal code (35 characters). If the answer is "No" the system corrects the ZIP Code upon pressing .

      Note:

      DO NOT generate the default ZIP Code without first entering the ZIP Code present on the form.

    17. Enter foreign street addresses in the street Address field, foreign city in the City field, foreign province in the State/Province field, and country and foreign postal code in the ZIP/Foreign Postal Code field. Use abbreviations as necessary to limit this entry to 35 positions.

    18. Enter Army Post Office (APO), Diplomatic Post Office (DPO) and Fleet Post Office (FPO) addresses with the proper two-character state code followed by the corresponding unique five-digit ZIP Code.

    19. When an APO, DPO or FPO is used, do not enter any other data in the City field.

    20. If the ZIP Code is out of range on APO, DPO or FPO addresses, enter 34001 for Miami, 09001 for New York and 96201 for San Francisco or Seattle.

    21. When APO, DPO or FPO is put in the City field, the state code field must correspond with the tables below.

    Valid Zone Improvement Plan (ZIP) Code for APO, DPO and FPO

    State CodeZIP Code RangeGeographic Location
    AA340Americas
    AE090-098Europe
    AP962-966Pacific

     

    Example:

    EXAMPLE:ENTER AS:
    APO New York, NY 091XXAPO AE 091XX
    FPO San Francisco, CA 962XXFPO AP 962XX

3.41.267.9.4 (02-19-2016)

Transmittal Taxpayer Identification Number (TIN)

  1. Each transmittal Form 1094 (series) return must have a complete nine-digit (numeric) employer identification number (EIN) present as a processable UW.

  2. If the EIN is a single repeating digit such as 111111111, 222222222, etc., or sequential 123456789 then the submission is considered unprocessable.

  3. If no EIN is present and an SSN format is present suspend the UW. The format for EIN is NN-NNNNNNN and the format for SSN is NNN-NN-NNNN.

  4. If the TIN/EIN is missing, illegible, or has more than or less than nine-digits on Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns, and it is found on the first detail document or determined enter the EIN from the first detail document (Line 8) in the field.

    Reminder:

    You cannot secure the filers EIN for Form 1094-B, Transmittal of Health Coverage Information Returns, from the details Form 1095-B, Health Coverage.

  5. If the complete EIN for a transmittal is not found on the return submission delete the UW by placing nine zeros (000000000) in the EIN field.

3.41.267.9.5 (04-23-2018)

Money Amount Fields

  1. Money fields consist of dollars only.

  2. Enter money amounts as follows:

    1. If a dollar amount is present and no cents, enter dollar amount.

    2. If a dollars and cents amount is present, enter the dollars only.

      Note:

      Do not round the dollars up or down based on cents if present.

    3. If a dollar amount is present and it is followed by a line, dash or hyphen, enter the dollar amount.

    4. If a dollar amount is present and the cents is lined through, enter dollar amount.

    5. If a dollar amount of 0 or 00 is present enter a single 0.

    6. If money amount is a negative zero (e.g., -00, -0.00. -00.00, etc.), remove it. Press to clear the field, and then press the space bar then .

  3. Do not enter negative amounts (identified with a minus (-) before the amount or the amount is within brackets).

  4. If two or more money amounts appear on the same line, press to clear the field and then enter the first dollar amount present.

  5. If the money amount is illegible, suspend the UW as "Poor Quality Image" (; press "S" ; select "Poor Quality Image" ).

  6. If after suspending for "Poor Quality Image" you still cannot determine the correct money amount from the physical document, press to clear the field and then press the space bar then .

  7. If a code or other non-monetary entry is present in a monetary field press to clear the field, then press the space bar followed by .

3.41.267.9.6 (01-01-2017)

Deleting a Unit-of-Work or Submission

  1. To delete a filer's entire submission (or UW, or transmittal), enter nine zeros in the EIN (Line 2) or "00" in the tax year of the Form 1094 (series) return.

  2. Pull and send the deleted Form 1094 (series) and all the associated detail documents back to the IRP Sort function. Deleting a submission is usually a procedure used by a manager or work leader.

  3. Always delete a submission if:

    • The detail document Form 1095-C, Employer-Provided Health Insurance Offer and Coverage, line 7 and 8, Applicable Large Employer Member (Employer), does not match the employer present on Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns.

    • The filer changed box titles.

    • The tax year is not clear.

    • The tax year of the transmittal and all the detail documents do not match.

    • The tax year is invalid including future tax years.

    • The incorrect detail document type is selected during "FI."

    • The Form 1094 (series) return is missing either the name (Line 1) or EIN (Line 2) of the filer or employer.

      Exception:

      On Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns, if Line 1-2 is blank and Line 9-10 is not blank, SCRIPS moves the Line 9-10 entity data to Line 1-2 entity data systemically after operator verification of the data fields.

    • The Form 1094 (series) return first four characters of the filer or employer name is illegible and is not retrievable within the submission.

3.41.267.9.7 (01-01-2022)

Voiding a Supporting Detail Document

  1. A supporting detail document is a Form 1095 (series) only.

  2. Void an individual detail Form 1095 (series) document if:

    • The void box on the top of the form is marked.

    • The form is crossed out or the word VOID is written over or across it.

      Note:

      The void box marked by the filer or employer makes all data on the form invalid.

    • The void box and corrected box both appear checked.

    • The only data on the document (detail) present is the Part I entity data AND the detail is not marked corrected (the CORRECTED box is not marked).

    • The form is a summary record in the submission.

      Example:

      The form is marked by the filer as a "summary, total, or subtotal" form.

    • The form is blank.

    • Detail documents (Form 1095 series) presented consecutively with the same responsible individual or employee and the same covered individuals duplicated, enter one document and VOID the duplicate(s).

    • The printed physical form is missing data due to improper printing of the form by the taxpayer.

    • One or two Form 1095-C documents have a different employer than the rest of the documents.

    • You can determine several Form 1095-C documents do not belong in the submission.

  3. DO NOT void a document (detail) if the system misread and placed an "X" in either the void or corrected boxes when one is not present on the document.

3.41.267.10 (01-01-2018)

Re-Imaging Form 1094 Series Returns

  1. The key allows you to flag or mark a Form 1094 (series) return to go to Image Only processing.

  2. Perform Re-image (Image only) processing when the true and complete image is not clear or complete.

  3. Re-image the return if any page of the return has processable taxpayer entries and the following exist:

    • Skewed, folded or otherwise unreadable

    • Scanned in backwards

3.41.267.11 (01-01-2018)

Form 1094 Series Image Only Processing

  1. SCRIPS scanning function for image only processing and archiving is done for submissions processed for re-imaging (the key is used) or processed using OE paper. Only a true and complete image is taken for this purpose. To allow for retrieval of the image in the future, the DLN is key entered with each image. The menus shown on the screen depend on how your supervisor profiled you.

    Example:

    This option is not present on the Data Validation Function Menu if it is not in your profile.

3.41.267.11.1 (01-01-2022)

Form 1094 Image Only

  1. From the Workstation Main Menu, select Data Validation (DV).

  2. From the Data Validation (DV) Selection Menu, select IRP ACA Form 1094 Image Only.

  3. A Form 1094 Image Only block opens with up to 100 records/returns.

    Note:

    100 records or returns equal more than 100 images due to multiple page records/returns.

  4. If an image is not recognized by the scanner, a window opens allowing you to identify the image and page of each image of Form 1094-B, Transmittal of Health Coverage Information Returns, or Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns. You can remove a single image or entire block from further processing. The window offers the options below:

    DV Image Only Selection

    Screen SelectionForm/Page/ (Form ID)
    AForm 1094-B pg. 1 (110116)
    BForm 1094-C pg. 1 (120118)
    CForm 1094-C pg. 2 (120218)
    DForm 1094-C pg. 3 (120316)
    XRemove

     

    1. If the image is not either form type/page number, then press to remove the document from further processing.

    2. Press -- or -- key combination to remove the entire block.

    3. If the image is identified as a Form 1094 series form type page 1 then the DLN is entered. If the document is removed or not a page 1, a DLN is not assigned or entered.

  5. If the record/return is the same block number, only the two-digit sequence number is entered. If the block number changes, then enter the 14-digit DLN.

  6. Whenever a 14-digit DLN is entered, the DLN is validated by requiring you to enter it twice. Each component of the DLN (i.e., the File Location Code, Tax Class, Document (Doc) Code, Julian Date, Blocking Series, Sequence Number and Year Digit) undergoes validation. Any invalid component generates an error message explaining the error.

3.41.267.12 (01-01-2020)

Supervisor Section Affordable Care Act Return Program Reports

  1. The following is a listing of the Affordable Care Act information return reports available on SCRIPS:

    • IRM 3.41.267.12.1, Document Locator Number (DLN) Output Report

    • IRM 3.41.267.12.2, Assigned Document Locator Number (DLN) Report

    • IRM 3.41.267.12.3, Cumulative Document Locator Number (DLN) Assignment Report

    • IRM 3.41.267.12.4, Workflow Status Report

    • IRM 3.41.267.12.5, Override Report

    • IRM 3.41.267.12.6, Inventory Report

    • IRM 3.41.267.12.7, Production Report

    • IRM 3.41.267.12.8, Run Balancing Report

    • IRM 3.41.267.12.9, Pull Unit of Work (Submission) Report

    • IRM 3.41.267.12.10, Throughput Statistics Report

    • IRM 3.41.267.12.11, Workstation Operator Statistics - Program and Function Summary Report

  2. The following subsections have the content found on the report.

3.41.267.12.1 (01-01-2016)

Document Locator Number (DLN) Output Report

  1. The title of the report is IRP ACA DLN Output Report (IPS01118).

  2. The report reflects the entire production for the site for a given time frame.

  3. The report has the following:

    1. Service Center

    2. Run Date

    3. Page number

    4. Program number

    5. DLNs and a notation if it is a transmittal DLN or detail DLN

    6. File Location Code (FLC), Tax Class and Document Code (TAX/DOC), Julian date, Block number and Volume

3.41.267.12.2 (01-01-2016)

Assigned Document Locator Number Report

  1. The title of the report is IRP ACA Assigned DLN Report (IPS03339).

  2. The report reflects production for the individual scanner for a given time frame.

  3. The report has the following:

    1. Program number

    2. Run Date and Time

    3. Scanner Job ID

    4. Start Time

    5. End Time

    6. DLNs and a notation if it is a transmittal DLN or detail DLN

    7. File Location Code (FLC), Tax Class and Document Code (TAX/DOC), Julian date, Block number and Volume

    8. The summary page for the scan job by document code and form type

3.41.267.12.3 (05-03-2017)

Cumulative Document Locator Number (DLN) Assignment Report

  1. The title of the report is IRP ACA Cumulative DLN Assignment Report (IPS11110).

  2. The report reflects the total number of DLN assignments by form type and form page time frame.

  3. The report has the following:

    1. Doc Code - Document Code
      Four-digits, digit one and two is the document code
      Digits three and four represent the page number

    2. Form
      Form number followed by page number (P1, P2, P3, etc.)

    3. Volume

    4. Total

    5. End Time

3.41.267.12.4 (01-01-2020)

Workflow Status

  1. The title of the report is Workflow Status (IPS0698).

  2. This report lists the task/sub-task number, the sub-task description, blocks at the sub-task, total documents for the block, and documents ready for the sub-task. This report also has percentages for system capacity used under the following three categories: General, IRP, and IRP/ACA/K1/941/940/Stand-Alone.

  3. This report is used to monitor documents and system capacity throughout each workday.

3.41.267.12.5 (01-01-2018)

Override Report

  1. The title of the report is IRP ACA Override Report (IPS11100).

  2. The report reflects the total count of override keystrokes for a given time frame.

  3. The report has the following:

    1. Function Code

    2. Doc Code - Document Code
      two-digit number

    3. Field Number

    4. Field Description

    5. Override Count

    6. End Time

3.41.267.12.6 (01-01-2016)

Inventory Report

  1. The title of the report is Inventory Report (IPS03350).

  2. The report reflects inventory for a given time frame reflecting the carry over form volume on SCRIPS.

  3. The report has the following:

    1. Initial Inventory

    2. Process Date

    3. Returns Input

    4. Returns Deleted

    5. Returns Output

    6. Carry Over Inventory

    7. End Time

3.41.267.12.7 (02-19-2020)

Production Report

  1. The title of the report is IRP ACA Production Report (IPS11120).

  2. The report reflects the following scanned volumes and year to date output totals.

  3. The report has the following:

    1. Service Center

    2. Run Date and Clock Time

    3. Page number

    4. Scanned volumes by document code and form type for today, subtotals and totals

    5. Output volumes by document code and form type and deletes for year to date along with cumulative, subtotals and totals

    6. Status summary for all functions for today/current and year to date cumulative

  4. This report records ACA IRP production though the processing year and, as possible, daily activity and aids in validating production volume. Use this report for analyzing production reports for accuracy.

  5. Site staff generates the IRP ACA Production Report late Friday or early Monday weekly and e-mails it by close of business Monday (or first workday of the work week) to National Office at *IT SCRIPS PO every week.

3.41.267.12.8 (02-19-2016)

Run Balancing Report

  1. The title of the report is IRP ACA Run Balancing Report (IPS01119).

  2. The report reflects the entire production for the site for a given date.

  3. The report has the following:

    1. Service Center

    2. Run Date

    3. Page number

    4. FTP File ID number

    5. The file name (i.e., OCR1010B for forms in the B series and OCR1010C for forms in the C series)

3.41.267.12.9 (01-01-2026)

Pull Unit of Work (Submission) Report

  1. The title of the report is IRP ACA Pull Document/Submission Report (IPS00812).

  2. The report lists submissions and documents to pull (or counted as deleted) for a date range.

  3. The report has the following:

    1. Service Center

    2. Run Date and clock time

    3. Page# - Number

    4. Block#

    5. Doc DLN/Seq# - Document DLN Sequence number

    6. App - Application FI, OE or DV

    7. SEID - Standard Employee Identification

      Note:

      An SEID of 000000 represents the SCRIPS system and creates the action based on programming and or specific responses to questions posed to the clerk.

    8. Date/Time

    9. Reason

  4. The reason is one of the following pull document report codes:

    Reminder:

    See IRM 3.41.267.4.2, Unprocessable Unit-of-Work Disposition, to determine the disposition of the UWs and documents pulled. Most of the pull report work requires forwarding to IRP Sort for correspondence as unprocessable documents. Tag each condition prior to forwarding to IRP Sort.

    Report ReasonCondition
    SINGLE ORIGINAL Form 1094-CStand-alone Original Form 1094-C
    CONSECUTIVE PARENTTwo consecutive Form 1094-X
    MISSING PARENT NAMEName missing from Form 1094-B (Line 1) or Form 1094-C (Line 1 and Line 9) transmittal return
    MISSING PARENT EINMissing valid nine-digit EIN on Form 1094 series return
    MIXED SUBMISSIONMixed form types ### Example: Marked "Remove" in FI.
    INVALID TAX YEARInvalid Tax Year
    PULL IMAGE ONLYMarked "Remove" in Image Only ### Note: Requires rescanning.
    PULL is pressed to remove document in OE/DV
    PULL STANDALONE Form 1094-BStand-alone Form 1094-B
    PULL IMAGE ONLY - NO DLN is pressed in Image Only on recognized document ### Note: Requires rescanning.
    DEL UW - INVALID SSN/INVALID DOBThreshold: Form 1095-B – Line 2/Line 3
    DEL UW - INVALID DOBThreshold: Form 1095-B – Line 3
    DEL UW - INVALID ORIGIN OF POLICYThreshold: Form 1095-B – Line 8
    DEL UW - INVALID EINSThreshold: Form 1095-B – Line 11
    DEL UW - INVALID SSN/INVALID DOBThreshold: Form 1095-B – Line 23(b)-40(b) SSN/DOB
    DEL UW - INVALID DOBThreshold: Form 1095-B – Line 23(c)-40(c) DOB
    DEL UW - INVALID MONTH COMBOThreshold: Form 1095-B – Line 23(d)-40(d) Months Covered
    DEL UW - INVALID NAMEThreshold: Form 1094-C – Line 1
    DEL UW - INVALID MISSING NAME/SSNThreshold: Form 1095-C – Line 1/Line 2
    DEL UW - INVALID SSNSThreshold: Form 1095-C – Line 2
    INVALID PLAN MONTHThreshold: Form 1095-C – Plan Month
    DEL UW - INVALID SSN/INVALID DOBThreshold: Form 1095-C Tax Year ≥ 2022 = Line 18-30(b)-Line 18-30(c)
    DEL UW - INVALID DOBThreshold: Form 1095-C Tax Year ≥ 2022 = Line 18-30(c)
  5. Physically pull only documents on the Pull Document Report for correspondence, Re-imaging or routing to some other function for action. Do not physically pull the following:

    • Blank pages

    • Instruction pages

    • Duplicate pages deleted by clerks

    • Extraneous pages sent by the filer when the UW is sent to output successfully

3.41.267.12.10 (05-03-2017)

Throughput Statistics Report

  1. The title of the report is Throughput Statistics Report (IPS06440).

  2. The report reflects processing function productions for a given date range.

  3. The report rows reflect the following process functions: Scandriver, Transport/Sync, OE Crossover, Form Identification, Block Verification, OE Image, OE Paper, Program Validation, Data Validation, QR Summarization, Block Output, Image Archive, Backup Image Archive and Block Purge.

  4. The report has the following:

    1. Service Center

    2. From and to date range and clock time

    3. Run Date and clock time

    4. Page Number

    5. Processing Function

    6. Total Blocks

    7. Total Documents

    8. Process Time

    9. Documents Per Hour

3.41.267.12.11 (05-03-2017)

Workstation Operator Statistics Program and Function Summary Report

  1. The title of the report is Workstation Operator Statistics Program and Function Summary Report (IPS00803).

  2. The report displays the number of documents processed in each function for a given date range.

  3. Process function listed on the report rows: 460, 470, 480, 47X, and 48X.

  4. The report has the following:

    1. Service Center

    2. From and to date range

    3. Run Date and clock time

    4. Page Number

    5. Function Code

    6. Program Number

    7. Number of Documents

    8. Process Time

    9. Total Keystrokes

    10. Keystrokes Per Hour

    11. Documents Per Hour

    12. Summary by Programs

3.41.267.13 (01-01-2018)

Block Status Window

  1. The Block Status window shows a more detailed status of the blocks/UWs in the search criteria data entered in the Block Search Criteria window.

  2. A change of operational parameters of blocks/UWs is completed in the Block Status window. Depending on the parameter, a change to the parameter for individual blocks/UWs or multiple blocks/UWs is completed at the same time.

    1. Press the -A key combination for selection of all blocks eligible for selection. This excludes blocks in a status of "DELETE" or "DONE." The result is a check symbol mark on selected blocks in the Block Selected for Update column.

    2. Press the -A key combination again to deselect all blocks if you choose to not perform updates on the selected blocks.

    3. Press the -X key combination if you choose to cancel the blocks selected and close the Block Status window.

  3. Block status monitoring (IPS0697) window shows a more detailed status of the blocks/UWs.

3.41.267.13.1 (01-29-2019)

Output Verification Audit

  1. An output verification process ran on all UWs prior to output systemically suspends any UW with invalid conditions in the UW, after DV.

  2. Report UWs with invalid conditions appearing on the Block Status Monitoring window (IPS0697) to System Administrators (SA) for researched by the contractor.

  3. A separate ticket is opened for each unique eleven or fourteen-digit DLN present on the report.

  4. The reason is one of the following pull document report codes:

    Reason CodeStatusOutput Verification Audit/ Description
    DUPDLNSUSPNDDuplicate DLN across a block (11-digit DLN) the block is previously output and therefore is a duplicate DLN
    BADDLNSUSPNDDLN is not 14 characters in length not numeric or where characters four or five not valid document code
    BADDOCSUSPNDThe block/UW has one or more documents not properly completed in the sub-task. document status between one and 699 (700 is "normal" )
    BADTINSUSPNDTIN not nine characters in length not numeric
    BADUWSUSPNDStand-alone Form 1094-B submission stand-alone Form 1094-C submission, original (not corrected) submission with no valid (non-deleted) documents
    BADDATSUSPNDForm 1095-X document with a valid status and VOID box checked Form 1094-B with no filer name, box 1 (a required field) question marks on a non-voided document in any field with any documents with a field equaling a status > 10 (not perfected) on a non-voided document
    DELETEForm 1094-C with no Applicable Large Employer (ALE) member name, box 1 (a required field)

3.41.267.14 (01-01-2019)

Purging Documents

  1. Purge from SCRIPS the files including the document images, American Standard Code for Information Interchange (ASCII data), and statistical information once the blocks/UWs of documents process through SCRIPS and reach "accepted" by down-stream processing, and the transmittals have moved to archive.

    Note:

    Accepted means the output files and "the returns in those files" clear all error conditions.

  2. It is recommended a system purge occur a minimum of two weeks after the output date.

  3. Purge only those blocks/UWs available for purge. The system keeps track of blocks/UWs available for purge and only allows you to purge those blocks/UWs. SCRIPS does not allow any blocks waiting for Quality Review (QR) Block Summarization or flagged for Quality Review to purge.

  4. Do not purge files for reports before six weeks.

    Exception:

    Reports allow deletion after seven working days however six weeks is the preference.

  5. A deleted document and/or block/UW is removed from the system when the form type is purged. The remainder of the form types on SCRIPS operate in the same manner.

    Example:

    Information return document (UW) is removed when an information return block purge is performed.

  6. A purge for the form type is initiated and activated before removal of deleted documents/blocks/UWs from the system. If you open a purge window but do not select any blocks for purge, the deleted documents/blocks/UWs do not leave the system. Until the deletion is properly done documents/blocks/UWs remain on the system.

  7. Retained for 30 days after data is verified as converted to tape per Document 12990, Records and Information Management Records Control Schedules, Record Control Schedule (RCS) 29, item 85, Information Returns, the physical documents (UWs scanned in the SCRIPS area). If systemic issues exist for downstream systems a longer period is enforced by headquarters staff.

Exhibit 3.41.267-1

Terms/Acronyms/Definitions

TERM/ACRONYMDEFINITION
ACA IRP ACA-IRP ACA IRP IRP-ACAAffordable Care Act form types in the Form 1094 (series) or Form 1095 (series) of returns. ### Reminder: These instructions cover only form types listed in IRM 3.41.267.2.1, Sources Documents.
ALEApplicable Large Employer employs 50 or more full-time equivalent employees alone, is the controlling group entity or common owner of multiple business entities with employees as defined under aggregation rules.
ALE MemberApplicable Large Employer Member is part of a group business entity and employs 50 or more full-time equivalent employees.
Alpha CharacterA character (letter) of the alphabet.
Alphanumeric FieldA field with both alpha and numeric characters.
APOArmy Post Office.
ApplicationRefers to the system used for form type processed (i.e., IRP, ACA-IRP, Schedule K-1s, Form 940, Form 941, Stand-alone Schedule Rs).
ASCIIAmerican Standard Code for Information Interchange, is the most common character encoding format for text data in computers and on the internet.
Block DLNThe first 11-digits of 14-digit document locator number (DLN) consisting of a two-digit file location code, tax class, (tax class is always "5" for ACA IRP), two-digit document type, three-digit Julian day, three-digit block number. Also see DLN.
CaptureThe process of obtaining images of a document for character recognition and operator use.
CharacterAny symbol or alpha (special or numeric) representing information.
Character RecognitionThe process of converting information from paper images to digital data form.
Corrected DocumentA return with the corrected box marked or a filer notation such as the word amended or corrected notated on the return.
CursorA vertical line showing the position where the next entry is keyed.
Data FieldsThose fields other than entity fields on all documents listed such as: money amounts, dates, indicators, covered individuals, etc.
Detail DocumentEvery Form 1095 (series) also referred to as supporting return or document or a child return.
DLN (Document Locator Number)A 14-digit document locator number consisting of a two-digit file location code, tax class, (tax class is always "5" for ACA IRP), two-digit document type, three-digit Julian day, three-digit block number, two-digit sequence number and a year digit. Also see Block DLN.
DOB (Date of Birth)A date consisting of a month, day and year combination. ### Caution: Any of the three missing means the remaining combination is not a DOB. Do not enter anything in the field without all three things present or determined.
Document Code (Doc Code)The fourth and fifth position of each DLN identifying the type of return the electronic data record has captured. The following is the document code - form number and form title for ACA-IRP. * 11 - Form 1094-B, Transmittal of Health Coverage Information Returns * 12 - Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns * 56 - Form 1095-B, Health Coverage * 60 - Form 1095-C, Employer-Provided Health Insurance Offer and Coverage
DPODiplomatic Post Office.
EINAn employer identification number (a nine-digit number) typically identifies an entity such as a corporation, a trust, a nonprofit association, or a sole proprietor whose module resides on the business master file. Usually in NN-NNNNNNN format.
EmployeeA recipient listed in Part I of Form 1095-C, Employer-Provided Health Insurance Offer and Coverage, issued by their employer (ALE).
Entity/Entity FieldsThe part of the document where the TIN, name, and requests an address present for the entries.
FieldSpecific area provided for data entry.
FilerThe entity listed on the transmitting Form 1094 (series) always a business entity with a corresponding employer identification number (EIN) or the employer.
FlagA question mark used to designate an unrecognizable character, or an error within a field. also flags a Form 1094 series for re-image.
File Location Code (FLC)A two-digit number designed to represent the Service Center where processing action occurs. The action is a transaction representing a return filing or subsequent compliance action.
Form Identification Number (Form ID)A six-digit number located at the top right of each page of a SCRIPS ACA IRP document. * First two-digits = Document Code * Third and fourth digit = Page number of the return * Fifth and sixth number = Year the template (layout or landscape placement) is last updated/changed
FPOFleet Post Office.
Function KeysThe upper row of keys on the SCRIPS keyboard. The function keys through .
HighlightingA three-dimensional shadowing of a template field used to direct attention to the field. Used in OE to show the current cursor position. Used in DV to show the current cursor position, and the current field with the error. The -5 function key highlights the corresponding field on the image template.
Image StripA section of the true and complete image magnified and displayed above the template. The image strip displayed is a magnified version of the corresponding field highlighted on the image. Pressing -3 toggles the image strip on and off. ### Reminder: The Image Strip will not display if the form required Form Identification (FI) during scanning.
Key CombinationKeystroke commands requiring two or more simultaneous key presses. ### Example: Press -P or post-to-close means to press and hold the key and then press the

key before releasing the key.

MenuA list of operations/options the workstation operator selects.
Message WindowA window appearing within the main window. It usually appears in the center of the screen. The system uses these windows to relay messages to the operator.
NABRName and Address Block Reader compares the address captured from the scanner and the United States Postal Service database of addresses.
Non-Conforming FormA form the scanner cannot recognize.
Numeric CharacterA number ranging from 0 to 9. A digit.
Original DocumentA return without a corrected box marked, amended or corrected notated by the filer on the return.
PromptA message or statement displayed requiring an operator response.
RecipientThe individual taxpayer listed in Part I of the Form 1095 (series) return who is the employee or responsible individual.
Responsible IndividualThe entity listed in Part 1 of Form 1095-B, Health Coverage, who is the holder, controller or owner of the insurance policy.
SA Form 1094CStand-alone Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns, with no details. See IRM 3.41.267.2.1 (1), Source Documents, for more information.
Sequence Number/ Serial Number (SN)A two-digit number located at positions 12 and 13 within the DLN and uniquely identifies the document.
Sight-VerifyExamine a highlighted field in DV. If correct, release the field. If incorrect, correct the field. Also, called verify.
Social Security Number (SSN)A nine-digit number issued to an individual by the Social Security Administration. The IRS uses this number to process tax documents and returns. Usually in NNN-NN-NNNN format.
Special Characters (symbols)\*, &, /, -, %, #, ?, etc. ### Note: Ampersand "&" is not considered a special character in the name line entry.
Status LineA strip of information found along the bottom right side of the main working window below the prompt area. This shows the program number, DLN/SN, document count, and AUTO, Insert and Numeric indicators.
SubmissionA Form 1094 (series) return with associated detail documents, Form 1095 (series), or a SA Form 1094C. Also, called a unit of work (UW).
TemplateA window with fields for data entry. The template mirrors the actual form layout, to the fullest extent possible.
TINTaxpayer Identification Number. Either an EIN or an SSN.
Transmittal (Parent document) (Parent return)A Form 1094-B, Transmittal of Health Coverage Information Returns, or Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns, filed with the IRS.
True and Complete ImageThe image the system displays for data entry or validation purposes. If available, the system always displays it on the left half of the monitor screen.
Unit-of-Work (UW)A group of ACA IRP documents with one Form 1094 (series) transmittal and corresponding Form 1095 (series) returns or one SA Form 1094C as defined. SCRIPS controls a unit-of-work by the Form 1094 (series) 14-digit DLN.
YYTYThe tax year processed normally current year minus one.
YYPYThe current processing year normally the current year. Term used to eliminate dates on form prompts changing each year.

Exhibit 3.41.267-2

States, State Codes, and Zone Improvement Plan (ZIP) Codes Sorted by State

If the ZIP Code is missing or invalid, add 01 to the first three-digit ZIP Code shown.

STATESTATE CODEZIP CODE RANGE
AlabamaAL350-369
AlaskaAK995-999
America SamoaAS96799 (only)
Americas APO/DPO/FPOAA340
ArizonaAZ850-865
ArkansasAR716-729
CaliforniaCA900-908, 910-961
ColoradoCO800-816
ConnecticutCT060-069
DelawareDE197-199
District of ColumbiaDC200, 202-205
Europe APO/DPO/FPOAE090-098
Federated States of MicronesiaFM969
FloridaFL320-342, 344, 346, 347, 349
GeorgiaGA300-319, 399
GuamGU969
HawaiiHI967, 968
IdahoID832-838
IllinoisIL600-629
IndianaIN460-479
IowaIA500-528
KansasKS660-679
KentuckyKY400-427
LouisianaLA700-714
MaineME039-049
Marshall IslandsMH969
MarylandMD206-219
MassachusettsMA010-027, 055
MichiganMI480-499
MinnesotaMN550-567
MississippiMS368-397
MissouriMO630-658
MontanaMT590-599
NebraskaNE680-693
NevadaNV889-898
New HampshireNH030-038
New JerseyNJ070-089
New MexicoNM870-884
New YorkNY005, 100-149
North CarolinaNC270-289
North DakotaND580-588
Northern Mariana IslandsMP969
OhioOH430-459
OklahomaOK730-732, 734-749
OregonOR970-979
Pacific APO/DPO/FPOAP962-966
PalauPW969
PennsylvaniaPA150-196
Puerto RicoPR006, 007, 009
Rhode IslandRI028, 029
South CarolinaSC290-299
South DakotaSD570-577
TennesseeTN370-385
TexasTX733, 750-799
UtahUT840-847
VermontVT050-054, 056-059
VirginiaVA201, 220-246
Virgin IslandsVI008
WashingtonWA980-986, 988-994
West VirginiaWV247-268
WisconsinWI530-549
WyomingWY820-831

Exhibit 3.41.267-3

States, State Codes, and Zone Improvement Plan (ZIP) Codes Sorted by ZIP Code

If the ZIP Code is missing or invalid, add 01 to the first three-digit ZIP Code shown.

ZIP CODE RANGESTATE CODESTATE
005, 100-149NYNew York
006, 007-009PRPuerto Rico
008VIVirgin Islands
010-027, 055MAMassachusetts
028, 029RIRhode Island
030-038NHNew Hampshire
039-049MEMaine
050-054, 056-059VTVermont
060-069CTConnecticut
070-089NJNew Jersey
090-098AEEurope APO/DPO/FPO
150-196PAPennsylvania
197-199DEDelaware
200, 202-205DCDistrict of Columbia
201, 220-246VAVirginia
206-219MDMaryland
247-268WVWest Virginia
270-289NCNorth Carolina
290-299SCSouth Carolina
300-319, 399GAGeorgia
320-342, 344, 346, 347, 349FLFlorida
340AAAmericas APO/DPO/FPO
350-369ALAlabama
370-385TNTennessee
386-397MSMississippi
400-427KYKentucky
430-459OHOhio
460-479INIndiana
480-499MIMichigan
500-528IAIowa
530-549WIWisconsin
550-567MNMinnesota
570-577SDSouth Dakota
580-588NDNorth Dakota
590-599MTMontana
600-629ILIllinois
630-658MOMissouri
660-679KSKansas
680-693NENebraska
700-714LALouisiana
716-729ARArkansas
730-732, 734-749OKOklahoma
733, 750-779TXTexas
800-816COColorado
820-831WYWyoming
832-838IDIdaho
840-847UTUtah
850-865AZArizona
870-884NMNew Mexico
889-898NVNevada
900-908, 910-961CACalifornia
962-966APPacific APO/DPO/FPO
96799 (only)ASAmerican Samoa
967, 968HIHawaii
969PWPalau
969GUGuam
969MPMarianna Islands
970-979OROregon
980-986, 988-994WAWashington
995-999AKAlaska

Exhibit 3.41.267-4

Zone Improvement Plan (ZIP) Code, City, and State Exceptions

Exceptions to ZIP where State ZIP Code is five-digits

ZIPCITYSTATE
75502TexarkanaAR
45275AirportKY
71749Junction CityLA
03801Naval BaseME
20331Andrews AFBMD
06390Fishers IslandNY
73949TexhomaTX
20041Dulles Int'l AirportVA
20370Navy AnnexVA
20301PentagonVA
49936AlvinWI

Exhibit 3.41.267-5

Alphabetical Listing of Major Cities with Major City Codes and Zone Improvement Plan (ZIP) Codes

Major CityState CodeMajor City CodeZIP Code
AberdeenSDAD574
AbileneTXAB796
AkronOHAK443
AlbanyGAAY317
AlbanyNYAL122
AlbuquerqueNMAQ871
AlexandriaVAAX223
AlhambraCAYA918
AllentownPAAW181
AmarilloTXAM791
AnaheimCAAH928
AnchorageAKAN995-996
AndersonSCAJ296
Ann ArborMIAP481
ArlingtonTXIA760
ArlingtonVAAR222
ArvadaCOAV800, 804
AshevilleNCAS288
AthensGAAE306
AtlantaGAAT303, 311, 399
Atlantic CityNJAC084
AuburnALAF368
AugustaGAAG309
AugustaMEAA043
AuroraCOAZ800
AuroraILAO605
AustinTXAU733, 787
BakersfieldCABD933
BaltimoreMDBA212
Baton RougeLABR708
Battle CreekMIQK490
BeaumontTXBT777
BellinghamWABH982
BerkeleyCABE947
BethlehemPABM180
BillingsMTIB591
BiloxiMSBL395
BinghamtonNYBC139
BirminghamALBI352
BismarckNDBB585
BloomingtonINBQ474
BloomingtonMNBN554
Boca RatonFLBZ334
BoiseIDBS837
Bossier CityLABW711
BostonMABO021, 022
BoulderCOBV803
BradentonFLBG342
BremertonWABY983
BridgeportCTBP066
BronxNYBX104
BrooklynNYBK112
BrownsvilleTXBJ785
BuffaloNYBF142
BurlingtonVTBU054
CambridgeMACB021, 022
CamdenNJCD081
CantonOHCA447
Cape CoralFLCF339
CasperWYCZ826
Cedar RapidsIACR524
ChampaignILCX618
ChandlerAZYZ852
Chapel HillNCCJ275
CharlestonSCCT294
CharlestonWVCW253
CharlotteNCCE282
CharlottesvilleVACV229
ChattanoogaTNCG374
ChesapeakeVACP233
CheyenneWYCY820
ChicagoILCH606-608
Chula VistaCADV919
CincinnatiOHCN452, 459
ClarksvilleTNYN370
ClearwaterFLCQ337
ClevelandOHCL441
Colorado SpringsCOCS809
ColumbiaSCCU292
ColumbusGACM318, 319
ColumbusOHCO430, 432
Corpus ChristiTXCC783, 784
CranstonRIRT029
CumberlandMDCK215
DallasTXDA752, 753
DavenportIADP528
DaytonOHDY453, 454
Daytona BeachFLDF321
DearbornMIDB481
DecaturILDT625
DenverCODN800-802
Des MoinesIADM503, 509
DetroitMIDE482
DubuqueIADQ520
DuluthMNDL557, 558
DurhamNCDU277
East LansingMIET488
East OrangeNJEO070
East St LouisILES622
EastonPAEA180
El PasoTXEP799, 885
ElizabethNJEL072
EriePAER165
EugeneOREU974
EvanstonILEN602
EvansvilleINEV477
FairbanksAKFK997
Fall RiverMAFR027
Far RockawayNYRK110, 116
FargoNDFA581
FayettevilleARFB727
FayettevilleNCFN283
FlintMIFT485
FlorenceALFC356
FlorenceSCFE295
FlushingNYFG113
Fort LauderdaleFLFL333
Fort PierceFLFP349
Fort SmithARFS729
Fort WayneINFY468
Fort WorthTXFW761
FresnoCAFO936-938
GainesvilleFLGF326
GaithersburgMDGG208
GalvestonTXGA775
GarlandTXGD750
GaryINGY464
GastoniaNCGN280
GlendaleAZGE853
GlendaleCAGL912
Grand RapidsMIGR495
Great FallsMTGT594
GreeleyCOGC806
Green BayWIGB543
GreensboroNCGO274
GreenvilleSCGV296
GreenwoodMSGW389
HackensackNJHS076
HamiltonOHHA450
HammondINHM463
HamptonVAHP236
HarlingenTXHR785
HartfordCTHD061
HarrisburgPAHG171
HattiesburgMSHT394
HelenaMTHE596
HendersonNVHF890
HialeahFLHI330
High PointNCHC272
HollywoodFLHW330
HonoluluHIHL968
HoustonTXHO770, 772
HuntingtonWVHN257
Huntington BeachCAHB926
HuntsvilleALHU358
IndependenceMOIE640
IndianapolisININ462
InglewoodCAID903
IrvineCAIV926, 927
IrvingTXIR750
JacksonMSJN392
JacksonvilleFLJV322
JamaicaNYJA114
JamestownNYJM147
JanesvilleWIJE535
Jersey CityNJJC070, 073
Johnson CityTNJH376
JohnstownPAJO159
JolietILJT604
JonesboroARJB724
KalamazooMIKZ490
Kansas CityKSKA661
Kansas CityMOKC641, 649
KennewickWAKW993
KenoshaWIKE531
KingsportTNKP376
KnoxvilleTNKN379
LafayetteINLF479
LafayetteLALL705
Lake CharlesLALC706
LakelandFLLK338
LakewoodCOLW801, 802, 804
LancasterPALP176
LansingMILG489
LaredoTXLD780
Las CrucesNMLZ880
Las VegasNVLV891
LawrenceMALQ018
LewistonMELT042
LexingtonKYLX405
LincolnNELN685
Little RockARLR722
Long BeachCALB907, 908
Long Island CityNYLI111
LorainOHLO440
Los AngelesCALA900, 901
LouisvilleKYLE402
LowellMALM018
LubbockTXLU794
LynnMALY019
MaconGAMA312
MadisonWIMN537
ManchesterNHMR031
MariettaGAMT300
MelbourneFLML329
MemphisTNME375, 381
MeridianMSMD393
MesaAZMZ852
MetairieLAMI700
MiamiFLMF330-332
MilwaukeeWIMW532
MinneapolisMNMS554
MissoulaMTMM598
MobileALMO366
ModestoCAMC953
MonroeLAMB712
MontgomeryALMG361
MuskegonMIMK494
NapervilleILNP605
NashuaNHNS030
NashvilleTNNA372
NewarkNJNK071
New BedfordMAND027
New BrunswickNJNB089
New HavenCTNH065
New OrleansLANO701
Newport NewsVANN236
NewtonMANE024
New YorkNYNY100-102
Niagara FallsNYNF143
NorfolkVANV235
NormanOKNR730
North CharlestonSCNC294
North HollywoodCANW916
North Las VegasNVNT890
North Little RockARNL721
OaklandCAOA946
Oak ParkILOP603
OceansideCAOE920
OgdenUTOG842, 844
Oklahoma CityOKOC731
OlympiaWAOL985
OmahaNEOM681
OrlandoFLOR328
OshkoshWIOK549
Overland ParkKSOV662
OwensboroKYOW423
OxnardCAOX930
Palo AltoCAPQ943
ParkersburgWVPK261
ParmaOHPZ441
PasadenaCAPD910, 911
PatersonNJPN075
Pembroke PinesFLPP330
PensacolaFLPE325
PeoriaAZPY853
PeoriaILPL616
PetersburgVAPG238
PhiladelphiaPAPH190-192
PhoenixAZPX850
Pine BluffARPB716
PittsburghPAPI151, 152
PocatelloIDPC832
Port ArthurTXPA776
PortlandMEPT041
PortlandORPO972
PortsmouthNHPS038
PortsmouthVAPM237
ProvidenceRIPR029
ProvoUTPV846
PuebloCOPU810
Punta GordaFLPJ339
QuincyMAQU021, 022
RacineWIRA534
RaleighNCRL276
ReadingPARD196
RenoNVRE895
RichmondVARI231, 232
RiversideCARS925
RoanokeVARO240
RochesterNYRC146
Rock HillSCRH297
RockfordILRF611
SacramentoCASC942, 958
SaginawMISG486
SalemORXR973
SalinasCAYL939
Salt Lake CityUTXU841
San AntonioTXSO782
San BernardinoCASR924
San DiegoCASD921
San FranciscoCASF941
San JoseCASJ951
San JuanPRXJ009
Santa AnaCASA927
Santa BarbaraCASZ931
Santa FeNMYF875
SarasotaFLXS342
SavannahGAGS314
SchenectadyNYSK120, 123
ScottsdaleAZYS852
ScrantonPAXC185
SeattleWASE981
Shawnee MissionKSSM662
SheboyganWIXB530
ShreveportLASH711
Silver SpringMDSS209
Sioux CityIASX511
Sioux FallsSDIQ571
South BendINSB466
SpartanburgSCSQ293
SpokaneWASW992
SpringfieldILXL627
SpringfieldMAXA011
SpringfieldMOXO657, 658
SpringfieldOHXH455
StamfordCTST069
Staten IslandNYSI103
St JosephMOXM645
St LouisMOSL631
St PaulMNSU551
St PetersburgFLSP337
Sterling HeightsMIYH483
StocktonCASN952
SyracuseNYSY132
TacomaWATC984
TallahasseeFLTL323
TampaFLTA336
TempeAZTE852
Terre HauteINTH478
TitusvilleFLTT327
ToledoOHTO436
TorranceCATN905
TopekaKSTP666
TrentonNJTR086
TucsonAZTU857
TulsaOKTS741
TuscaloosaALTB354
UticaNYUT135
Van NuysCAVN913, 914
VancouverWAVA986
Virginia BeachVAVB234
WacoTXWX767
WarrenMIWR480
WarrenOHWO444
WarwickRIWW028
WashingtonDCDC200, 202-205, 569
WaterburyCTWT067
WaterlooIAWL507
West AllisWIWA532
West Valley CityUTWC841
West Palm BeachFLWP334
WestministerCOWD800, 802
WheelingWVWH260
White PlainsNYWJ106
WichitaKSWK672
Wichita FallsTXWF763
Wilkes-BarrePAWB187
WilliamsportPAWM177
WilmingtonDEWI198
WilmingtonNCWN284
Winston-SalemNCWS271
Winter HavenFLWG338
WorcesterMAWE016
YonkersNYYK107
YorkPAYR173, 174
YoungstownOHYO445

Exhibit 3.41.267-6

Affordable Care Act Information Return Transcription Sheets

OE/DV Screen PromptDescriptionInstructions Form 1094-B, Transmittal of Health Coverage Information Returns
Tax Year(located top right-hand of form)The tax year is a must enter field entry. * Enter the tax year printed/present in the upper right-hand corner of the form. * Requires two consecutive matching and valid entries to leave the field. ### Reminder: Valid tax years: 2025, 2024, 2023, and 2022. * Enter "00" if an invalid tax year is present, Then select "yes" when prompted to delete the UW. ### Note: The system 1) recognizes the tax year present and 2) presents the year for site verification before releasing from the field.
Delinquent IndicatorFirst box For Official Use OnlyEnter the code, if present, from the first For Official Use Only box. Notes: * If the box is blank, check if it is present in the top margin of the document. * If the code is ≡ ≡ ≡≡ ≡ ≡≡ ≡ ≡ ≡≡ ≡ ≡≡ ≡ ≡≡ ≡ ≡≡ ≡≡ ≡ ≡ ≡ ≡≡ ≡, do not enter data in the Delinquent Return Date field. * If the code is ≡ ≡≡ enter the valid date in the Delinquent Return Date field.
Delinquent Return DateDate stamp in white space of For Official Use OnlyEnter the date from the IRS received date stamp, if present. 1. If blank, enter the date from the IRS received date stamp in MMDDYY format see the valid dates below. 2. If multiple conflicting received dates present or the received date stamp is circled out leave blank. 3. If the received date stamp is illegible, enter the signature date. If the signature date is illegible, missing, or timely, leave blank. 4. The valid dates: ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡. * If the ≡ ≡ is missing and a valid Delinquent Date is present in the Delinquent Return Date field, enter an "≡ ≡ ≡" . * If the received date present is not valid remove the "≡ ≡" from the Delinquent Indicator field.
Corr. IndCorrespondence IndicatorDO NOT enter any codes present from the last two For Official Use Only boxes. Press .
Line 1- Filer's NameFiler’s nameEnter the full name shown. If any character in the name is illegible enter a space for the illegible character. If the name is missing and is not present delete the UW from the system. Press .
Line 2-EINEmployer identification number (EIN)Enter the nine-digit EIN present. ### Caution: Delete the UW by entering all zeros in the EIN field when: \- the TIN is missing or is more than or less than nine-digits \- any digit is illegible, and the filer entity is not present on the first detail \- single repeating digit such as 111111111, 222222222, etc., or sequential 123456789 is entered as the EIN.
Line 3-Name of ContactName of person to contactEnter the full name shown. If any character in the name is illegible enter a space for the illegible character. If the name is missing and is not present press .
Line 4-Contact PhoneContact telephone numberEnter up to the first twelve numbers if present. Is blank, 7, 10, or 12 numerics. ### Note: Extensions optional.
Line 5-AddressStreet addressEnter the street address from the form. If a foreign address, enter the address.
Line 6-CityCity or townEnter the name of the city. If a foreign address is present, enter the city.
Line 7-State/ProvinceState or provinceEnter the two-character code for the state listed on the document. If a foreign address, enter the province.
Line 8-Zip/Foreign Postal CodeCountry and ZIP or foreign postal codeEnter the five-digit ZIP Code. If missing, press to bypass this field. If a foreign address, enter the Country and/or foreign postal code.
Line 9-Total Form 1095-BTotal number of Forms 1095-B submitted with this transmittalEnter the number present on the document.
OE/DV Screen Prompt Page 1Description Page 1Instructions Form 1095-B, Health Coverage - Page 1
Tax Year(located top right-hand of form)The tax year is a must enter field entry. * Enter the tax year printed/present in the upper right-hand corner of the form. * Requires two consecutive matching and valid entries to leave the field. ### Reminder: Valid tax years: 2025, 2024, 2023, and 2022. * Enter "00" when an invalid tax year is present, or the year does not match the transmittal. Then select "yes" when prompted to delete the return. ### Note: The system 1) recognizes the tax year present and 2) presents the year for site verification before releasing from the field.
VoidVOID BoxEnter "X" if marked. ### Note: Consider all data invalid if the filer marks the void box, writes void on the form, marks through the entire form or the SCRIPS operator has voided the return due to duplication within the submission.
CorrectedCORRECTED BoxEnter "X" if marked.
Line 1-Resp. First NameFirst nameEnter the first name if present or you can determine it. If any character in the name is illegible enter a space for the illegible character. Do not leave two consecutive spaces. If it is not possible to determine first, middle initial and last name place the entire name in last/full name.
Line 1-Resp. Middle InitialMiddle initialEnter the middle initial if present or you can determine it.
Line 1-Resp. Last/Full NameLast name/Full nameEnter the last name. If any character in the name is illegible, enter a space for the illegible character. Do not leave two consecutive spaces. If it is not possible to determine first, middle initial, and last name place the entire name in this field. Enter suffixes after the last name entry.
Line 2-SSN or other TINSocial security number (SSN)Enter the nine-digit SSN or TIN present. * If the SSN is more than nine-digits enter the first nine-digits. * If any digit is illegible or missing enter a period for the illegible or missing digit. ### Exception: If 50 percent or more of the SSNs in the UW appear redacted, suspend under Supervisor Request. * If blank, single repeating digit such as 111111111, 222222222, etc., or sequential 123456789 do not enter data. Press . ### Exception: If 50 percent or more of the SSNs in the UW meet the conditions above suspend under Supervisor Request.
Line 3-Date of BirthDate of birth (if SSN is not available)Enter the date of birth if present in MMDDYYYY format if a complete date is present. ### Caution: If any of one of MM, DD or YYYY is missing, the remaining combination "is not" a DOB. Do not enter partial data in the field.
Line 4-AddressStreet addressEnter the street address from the form. If a foreign address, enter the address.
Line 5-CityCity or townEnter the name of the city. If a foreign address is present, enter the city.
Line 6-State/ProvinceState or provinceEnter the two-character code for the state listed on the document. If a foreign address, enter the province.
Line 7-Zip/Foreign Postal CodeCountry and ZIP or foreign postal codeEnter the five-digit ZIP Code. If missing, press to bypass this field. If a foreign address, enter the Country and/or foreign postal code.
Line 8-Origin of PolicyEnter letter identifying Origin of the Policy...▸Enter the alpha character present. * Valid characters: "A" through "G." * If multiple characters present enter the first valid character. * If no valid character is present blank the field.
Line 10-Emp. NameEmployer nameEnter the full name shown. If any character in the name is illegible enter a space for the illegible character. Do not leave two consecutive spaces.
Line 11-EINEmployer identification numberEnter the nine-digit EIN present. If the EIN is: * Missing enter nothing. * Is more than nine-digits enter the first nine-digits. * If any digit is illegible or missing enter a period for the illegible or missing digit.
Line 12-AddressStreet addressEnter the street address from the form. If a foreign address, enter the address.
Line 13-CityCity or townEnter the name of the city. If a foreign address is present, enter the city.
Line 14-State/ProvinceState or provinceEnter the two-character code for the state listed on the document. If a foreign address, enter the province.
Line 15-Zip/Foreign Postal CodeCountry and ZIP or foreign postal codeEnter the five-digit ZIP Code. If missing, press to bypass this field. If a foreign address, enter the Country and/or foreign postal code.
Line 16-NameEnter the full name shown. If any character in the name is illegible enter a space for the illegible character. Do not leave two consecutive spaces.
Line 17-EINEnter the nine-digit EIN present. * If the EIN is more than nine-digits enter the first nine-digits. * If any digit is illegible or missing enter a period for the illegible or missing digit.
Line 18-Contact PhoneContact telephone numberEnter up to the first twelve numbers if present. Is blank, 7, 10, or 12 numerics. ### Note: Extensions optional.
Line 19-AddressStreet addressEnter the street address from the form. If a foreign address, enter the address.
Line 20-CityCity or townEnter the name of the city. If a foreign address is present, enter the city.
Line 21-State/ProvinceState or provinceEnter the two-character code for the state listed on the document. If a foreign address, enter the province.
Line 22-Zip/Foreign Postal CodeCountry and ZIP or foreign postal codeEnter the five-digit ZIP Code. If missing, press to bypass this field. If a foreign address, enter the Country and/or foreign postal code.
Line 23(a)-Covered Ind. through Line 28(a)-Covered Ind. First NameFirst nameEnter the first name if present or if you can determine it. If any character in the name is illegible enter a space for the illegible character. Do not leave two consecutive spaces. If it is not possible to determine first, middle initial and last name place the entire name in last/full name. Enter suffixes after the last name entry.
Line 23(a)-Covered Ind. through Line 28(a)-Covered Ind. Middle InitialMiddle initialEnter the middle initial if present or you can determine it.
Line 23(a)-Covered Ind. through Line 28(a)-Covered Ind. Last/Full NameLast/Full nameEnter the last name. If any character in the name is illegible enter a space for the illegible character. Do not leave two consecutive spaces. If it is not possible to determine first, middle initial, and last name place the entire name in this field. Enter suffixes after the last name entry. ### Note: Instructions repeat for all entries for each covered individual listed on line 23, columns (a, b, c, d, and e) through line 28, columns (a, b, c, d, and e).
Line 23(b)-SSN or other TIN through Line 28(b)-SSN or other TINSSNEnter the nine-digit SSN or TIN present. * If the SSN is more than nine-digits enter the first nine-digits. * If any digit is illegible or missing enter a period for the illegible or missing digit. ### Exception: If 50 percent or more of the SSNs in the UW appear redacted suspend under Supervisor Request. * If blank, single repeating digit such as 111111111, 222222222, etc., or sequential 123456789 do not enter data. Press . ### Exception: If 50 percent or more of the SSNs in the UW meet the conditions above suspend under Supervisor Request. ### Caution: Do not enter any data present in columns (b, c, d, or e) if there is no corresponding name present in column (a).
Line 23(c)-DOB through Line 28(c)-DOBDOB (If SSN is not available)Enter the date of birth if present in MMDDYYYY format if a complete date is present. ### Caution: If any of one of MM, DD or YYYY appear missing the remaining combination "is not" a DOB. Do not enter partial data in the field. ### Caution: Do not enter any data present in columns (b, c, d, or e) if there is no corresponding name present in column (a).
Line 23(d)-12 Months through Line 28(d)-12 MonthsCovered all 12 monthsEnter "X" if marked. ### Caution: Do not enter any data present in columns (b, c, d, or e) if there is no corresponding name present in column (a).
Line 23(e)-Jan through Line 28(e)-DecMonths of coverage Jan through DecEnter "X" if marked. ### Note: Instructions repeat for all entries for each covered individual listed on line 23, columns (a, b, c, d, and e) through line 28, columns (a, b, c, d, and e). ### Caution: Do not enter any data present in columns (b, c, d, or e) if there is no corresponding name present in column (a).
OE/DV Screen Prompt Page 3Description Page 3Instructions Form 1095-B, Health Coverage - Page 3
SSNSocial security number (SSN)Enter the nine-digit SSN or TIN present. Enter a period for illegible characters. If blank, single repeating digit such as 111111111, 222222222, etc., or sequential 123456789 do not enter data. Press .
Date of BirthDate of birth (if SSN is not available)Enter the date of birth if present in MMDDYYYY format if a complete date is present. ### Caution: If any of one of MM, DD or YYYY is missing the remaining combination "is not" a DOB. Do not enter partial data in the field.
Line 29(a)-Covered Ind. through Line 40(a)-Covered Ind. First NameFirst nameEnter the first name if present or you can determine it. If any character in the name is illegible enter a space for the illegible character. Do not leave two consecutive spaces. If it is not possible to determine first, middle initial, and last name place the entire name in last/full name.
Line 29(a)-Covered Ind. through Line 40(a)-Covered Ind. Middle InitialMiddle initialEnter the middle initial if present or you can determine it.
Line 29(a)-Covered Ind. through Line 40(a)-Covered Ind. Last/Full NameLast name/Full nameEnter the last name. If any character in the name is illegible enter a space for the illegible character. Do not leave two consecutive spaces. If it is not possible to determine first, middle initial, and last name place the entire name in this field. Enter suffixes after the last name entry. ### Note: Instructions repeat for all entries for each covered individual listed on line 23 (columns a, b, c, d, and e) through line 40 (columns a, b, c, d, and e).
Line 29(b)-SSN through Line 40(b)-SSNSSN or other TINEnter the nine-digit SSN or TIN present. * If the SSN is more than nine-digits enter the first nine-digits. * If any digit is illegible or missing enter a period for the illegible or missing digit. ### Exception: If more than 50 percent of the SSNs in the UW appear redacted suspend under Supervisor Request. * If blank, single repeating digit such as 111111111, 222222222, etc., or sequential 123456789 do not enter data. Press . ### Exception: If 50 percent or more of the SSNs in the UW meet the conditions above suspend under Supervisor Request. ### Caution: Do not enter any data present in columns (b, c, d, or e) if there is no corresponding name present in column (a).
Line 29(c)-DOB through Line 40(c)-DOBDOB (If SSN or other TIN is not available)Enter the date of birth if present in MMDDYYYY format if a complete date is present. ### Caution: If any of one of MM, DD, or YYYY appear missing the remaining combination "is not" a DOB. Do not enter partial data in the field. ### Caution: Do not enter any data present in columns (b, c, d, or e) if there is no corresponding name present in column (a).
Line 29(d)-12 Months through Line 40(d)-12 MonthsCovered all 12 monthsEnter "X" if marked. ### Caution: Do not enter any data present in columns (b, c, d, or e) if there is no corresponding name present in column (a).
Line 29(e)-Jan through Line 40(e)-DecMonths of coverage Jan through DecEnter "X" if marked. ### Caution: Do not enter any data present in columns (b, c, d, or e) if there is no corresponding name present in column (a).
OE/DV Screen Prompt Page 1Description Page 1Instructions Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns - Page 1
Tax Year(located top right-hand of form)The tax year is a must enter field entry. * Enter the tax year printed/present in the upper right-hand corner of the form. * Requires two consecutive matching and valid entries to leave the field. ### Reminder: Valid tax years: 2025, 2024, 2023, and 2022. * Enter "00" if an invalid tax year is present. Then select "yes" when prompted to delete the UW. ### Note: The system 1) recognizes the tax year present and 2) presents the year for site verification before releasing from the field.
CorrectedCORRECTED BoxEnter "X" if marked.
Delinquent IndicatorFirst box For Official Use OnlyEnter the code, if present, from the first For Official Use Only box. Notes: * If the box is blank, look for a code in the top margin of the document. * If the code is ≡ ≡ ≡ ≡≡ ≡≡ ≡ ≡ ≡≡ ≡≡ ≡≡ ≡≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡, do not enter data in the Delinquent Return Date field. * If the code is "≡ ≡" , enter the valid date in the Delinquent Return Date field.
Delinquent Return DateDate stamp in white space of For Official Use OnlyEnter the date from the IRS received date stamp, if present. 1. If blank, enter the date from the IRS received date stamp in MMDDYY format see the valid dates below. 2. If multiple conflicting received dates present or the received date stamp is circled out leave blank. 3. If the received date stamp is illegible, enter the signature date. If the signature date is illegible, missing, or timely, leave blank. 4. The valid dates: ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ ≡ * If the "≡ ≡ ≡" is missing and a valid Delinquent Date is present in the Delinquent Return Date field, enter an "≡ ≡ ≡" . * If the received date is not valid remove the "≡ ≡ ≡" from the Delinquent Indicator field.
Corr. IndCorrespondence IndicatorDO NOT enter any codes present from the last two For Official Use Only boxes. Press .
Line 1-ALE MemberName of ALE Member (Employer)Enter the full name as shown if present. * If any character in the name is illegible enter a space for the illegible character. * Do not leave two consecutive spaces. * If the name is missing and is not present press . * See IRM 3.41.267.9.2, Name Entry, for more instruction on filers names.
Line 2-EINEmployer identification numberEnter the nine-digit EIN present. * If the EIN is missing, incomplete, invalid, or more than or less than nine-digits then check the first detail document for the EIN. If present enter on Line 2- EIN. * If the EIN is not present on the first detail AND line 9 and line 10 appear blank, then enter nine zeros (000000000) to delete the UW. * If there is no entry on line 1 and 2 and there is an entry on line 9 and line 10, the system moves the entity on line 9 and line 10 to line 1 and line 2 systemically. * If the EIN is a single repeating digit such as 111111111, 222222222, etc., or sequential 123456789 or is more than or less than nine-digits and the correct EIN is not present on the first detail then enter nine zeros (000000000) to delete the UW.
Line 3-AddressStreet addressEnter the street address from the form. If a foreign address, enter the address.
Line 4-CityCity or townEnter the name of the city. If a foreign address is present, enter the city.
Line 5-State/ProvinceState or provinceEnter the two-character code for the state listed on the document. If a foreign address, enter the province.
Line 6-Zip/Foreign Postal CodeCountry and ZIP or foreign postal codeEnter the five-digit ZIP Code. If missing, press to bypass this field. If a foreign address, enter the Country and/or foreign postal code.
Line 7-Name of ContactName of person to contactEnter the full name shown. If any character in the name is illegible enter a space for the illegible character. If the name is missing and is not present press .
Line 8-Contact PhoneContact telephone numberEnter up to the first twelve numbers if present. Is blank, 7, 10, or 12 numerics. ### Note: Extensions optional.
Line 9-Designated NameName of Designated Government Entity (only if applicable)Enter the full name shown. If any character in the name is illegible enter a space for the illegible character. If the name is missing and is not present press . ### Note: If there is no ALE data present on Line 1 and 2, and valid data is verified on Line 9 and 10 the designated entity data is moved to the ALE entity data systemically.
Line 10-EINEmployer identification number (EIN)Enter the nine-digit EIN present. * If there are entries on line 1 and line 2; and the EIN is missing, incomplete, or a single repeating digit such as 111111111, 222222222, etc., or sequential 123456789 or is less than nine-digits press do not enter data. Press****. * If there are entries on line 1 and line 2; and the TIN is more than nine-digits enter the first nine-digits present. * If there are entries on line 1 and line 2; and the TIN appears in SSN format enter nothing, press . * If there is no entry on line 1 and line 2 and the EIN is missing, incomplete, invalid, or more than or less than nine-digits, then enter nine zeros (000000000) to delete the UW. ### Note: If there is no entry on line 1 and 2 and there is a valid entry on line 9 and line 10 the system moves the entity on line 9 and line 10 to line 1 and line 2 systemically.
Line 11-AddressStreet addressEnter the street address from the form. If a foreign address, enter the address.
Line 12-CityCity or townEnter the name of the city. If a foreign address is present, enter the city.
Line 13-State/ProvinceState or provinceEnter the two-character code for the state listed on the document. If a foreign address, enter the province.
Line 14-Zip/Foreign Postal CodeCountry and ZIP or foreign postal codeEnter the five-digit ZIP Code. If missing, press to bypass this field. If a foreign address, enter the Country and/or foreign postal code.
Line 15-Name of ContactName of person to contactEnter the full name shown. If any character in the name is illegible enter a space for the illegible character. If the name is missing and is not present press .
Line 16-Contact PhoneContact telephone numberEnter up to the first twelve numbers if present. Is blank, 7, 10, or, 12 numerics. ### Note: Extensions optional.
Line 18-Total Form 1095-CsTotal number of Forms 1095-C submitted with this transmittalEnter the number present on the document.
Line 19-Authoritative ALE MemberIs this the authoritative transmittal for this ALE Member? If “yes,” check the box and continue...Enter "X" if marked.
Line 20-Total Form 1095-C on behalf of ALETotal number of Forms 1095-C filed by and/or on behalf of ALE Member...Enter the number if present. * Numbers only. * Leave the entry blank or blank the field if it has alpha characters or words.
Line 21-ALE Member of group-YesIs ALE Member a member of an Aggregated ALE group?... Yes boxEnter "X" if the "Yes" box is marked.
Line 21-ALE Member of group-NoIs ALE Member a member of an Aggregated ALE group?... No boxEnter "X" if the "No" box is marked.
Line 22-Offer MethodLine 22 box "A" Qualifying Offer MethodEnter "X" if the box is marked.
Line 22-98% OfferLine 22 box "D" 98% Offer MethodEnter "X" if the box is marked.
OE/DV Screen Prompt Page 2Description Page 2Instructions Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns - Page 2
Line 23-12 months-Essential Coverage-YesFirst check box in column (a) "Yes" row 23 Minimum Essential Coverage Offer Indicator labeled YesEnter an "X" if the "Yes" box is checked.
Line 23-12 months-Essential Coverage-NoSecond check box in column (a) "No" row 23 Minimum Essential Coverage Offer Indicator labeled NoEnter an "X" if the "No" box is checked.
Line 23-12 months-Full Time countColumn (b) Full-Time Employee Count for ALE MemberEnter the number from line 23 column (b) if present. * Whole numbers or blank is valid. * Do not enter fractions, decimal points, or numbers to the right of a decimal point. * Do not round up or down if a fractional or decimal is entered by the filer. * Do not enter zeros: 0, 00, 00.00, or, 0.00 etc.
Line 23-12 months-Total Emp. CountColumn (c) Total Employee Count for ALE MemberEnter the number from line 23 column (c) if present. * Whole numbers or blank is valid. * Do not enter fractions, decimal points, or numbers to the right of a decimal point. * Do not round up or down if a fractional or decimal is entered by the filer. * Do not enter zeros: 0, 00, 00.00, or, 0.00 etc.
Line 23-12 months-Agg. Group IndColumn (d) Aggregated Group IndicatorEnter an "X" if the box is checked.
Line 24-Jan-Essential Coverage-Yes through Line 35-Dec-Essential Coverage-YesFirst check box in column (a) "Yes" row 24 Minimum Essential Coverage Offer Indicator labeled YesEnter "X" if the "Yes" box is marked.
Line 24-Jan-Essential Coverage-No through Line 35-Dec-Essential Coverage-NoSecond check box in column (a) "No" row 24 Minimum Essential Coverage Offer Indicator labeled NoEnter "X" if the "No" box is marked. ### Note: Instructions repeat for all entries on line 23, All 12 Months, (row 2) to line 35, Dec, (row 14).
Line 24-Jan-Full-Time count through Line 35-Dec-Full Time countColumn (b) Section 4980H Full-Time Employee Count for ALE MemberEnter the number from line 24 column (b) if present.
Line 24-Jan-Total Emp. Count through Line 35-Dec-Total Emp. CountColumn (c) Total Employee Count for ALE MemberEnter the number from line 24 column (c) if present.
Line 24-Jan-Agg. Group Ind through Line 35-Dec-Agg. Group IndColumn (d) Aggregated Group IndicatorEnter an "X" if the box is checked.
OE/DV Screen Prompt Page 3Description Page 3Instructions Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns - Page 3
Line 36-NameName of Other ALE Members of Aggregated ALE GroupEnter the full name shown if present. Enter a space for any illegible characters. Do not leave two consecutive spaces.
Line 36-EINEIN of Other ALE Members of Aggregated ALE GroupEnter the EIN if present. * Enter a period for illegible characters. * If more than nine-digits enter the first nine-digits.
Line 37-65 \-NameName of Other ALE Members of Aggregated ALE GroupUse instruction for Line 36-Name for any entries present for Line 37-65-Name.
Line 37-65 \-EINEIN of Other ALE Members of Aggregated ALE GroupRepeat instruction for Line 36-EIN for any entries present for Line 37-65-EIN.
OE/DV Screen Prompt Page 1Description Page 1Instructions Form 1095-C, Employer-Provided Health Insurance Offer and Coverage - Page 1
Tax Year(located top right-hand of form)The tax year is a must enter field entry. * Enter the tax year printed/present in the upper right-hand corner of the form. * Requires two consecutive matching and valid entries to leave the field. ### Reminder: Valid tax years: 2025, 2024, 2023, and 2022. * Enter "00" when an invalid tax year is present, or the year does not match the transmittal. Then select "yes" when prompted to delete the return. ### Note: The system 1) recognizes the tax year present and 2) presents the year for site verification before releasing from the field.
VoidVOID BoxEnter "X" if marked or if the document is blank. ### Note: Consider all data on the form invalid if the filer marks the void box, writes void on the form, marks through the entire form or the SCRIPS operator has voided the return due to duplication within the submission.
CorrectedCORRECTED BoxEnter "X" if marked.
Line 1-Employee First NameEmployee first nameEnter the first name if present or you can determine it. If any character in the name is illegible enter a space for the illegible character. Do not leave two consecutive spaces. If it is not possible to determine first, middle initial, and last name place the entire name in last/full name.
Line 1-Employee Middle InitialEmployee middle initialEnter the middle initial if present or you can determine it.
Line 1-Employee Last/Full NameEmployee last name/full nameEnter the last name. If any character in the name is illegible enter a space for the illegible character. Do not leave two consecutive spaces. If it is not possible to determine first, middle initial, and last name place the entire name in this field. Enter suffixes after the last name entry.
Line 2-SSNSocial security number (SSN)Enter the nine-digit SSN present. * If the SSN is more than nine-digits enter the first nine-digits. * If any digit is illegible or missing enter a period for the illegible or missing digit. ### Exception: If more than 50 percent of the SSNs in the UW appear redacted suspend under Supervisor Request. * If blank, single repeating digit such as 111111111, 222222222, etc., or sequential 123456789 do not enter data. Press . ### Exception: If 50 percent or more of the SSNs in the UW meet the conditions above suspend under Supervisor Request.
Line 3-AddressStreet addressEnter the street address from the form. If a foreign address, enter the address.
Line 4-CityCity or townEnter the name of the city. If a foreign address is present, enter the city.
Line 5-State/ProvinceState or provinceEnter the two-character code for the state listed on the document. If a foreign address, enter the province.
Line 6-Zip/Foreign Postal CodeCountry and ZIP or foreign postal codeEnter the five-digit ZIP Code. If missing, press to bypass this field. If a foreign address, enter the Country and/or foreign postal code.
Line 7-Employer NameName employerEnter the full name shown. If any character in the name is illegible enter a space for the illegible character. Do not leave two consecutive spaces. If the name is missing and is not present press .
Line 8-EINEmployer identification numberEnter the nine-digit EIN present. If the EIN is missing or is more than or less than nine-digits press to perfect the EIN.
Line 9-AddressStreet addressEnter the street address from the form. If a foreign address, enter the address. ### Note: If the Address is incomplete or illegible press to perfect the data. See IRM 3.41.267.9 (10) for information.
Line 10-Contact PhoneContact telephone numberEnter up to the first twelve numbers if present. Is blank, 7, 10, or, 12 numerics. ### Note: Extensions optional.
Line 11-CityCity or townEnter the name of the city. If a foreign address is present, enter the city. ### Note: If the City is incomplete or illegible press to perfect the data. See IRM 3.41.267.9 (10) for information.
Line 12-State/ProvinceState or provinceEnter the two-character code for the state listed on the document. If a foreign address, enter the province. ### Note: If the State is incomplete or illegible press to perfect the data. See IRM 3.41.267.9 (10) for information.
Line 13-Zip/Foreign Postal CodeCountry and ZIP or foreign postal codeEnter the five-digit ZIP Code. If missing, press to bypass this field. If a foreign address, enter the Country and/or foreign postal code. ### Note: If the ZIP is incomplete or illegible press to perfect the data. See IRM 3.41.267.9 (10) for information.
Tax Years ≥ 2022 Part II Employee’s AgeEmployee’s Age on January 1Enter the number present. A number 1 through 120 or blank is valid. If no entry is present, or the entry is invalid or illegible blank the field. ### Example: Delete invalid entries such as 123 years old.
Part II-Plan MonthPlan Start Month (Enter a two-digit number):Enter the one or two-digit number present. 00 through 12 is valid. Enter 00 if no entry is present. If month is written in (January through December) or an abbreviation for a month (Jan through Dec) enter the corresponding two-digit month. ### Caution: Scan the entire Plan Start Month area for an entry.
Line 14-All 12 monthsOffer of Coverage (enter required code)Enter the numeric alpha combination present on the document. * Valid character combinations: "1A" through "1Z." * If multiple codes appear enter the first code combination in the column. * Remove invalid combinations. ### Example: Delete invalid combinations such as "A1" and "11."
Line 14-Jan through Line 14-DecOffer of Coverage (enter required code)Enter the numeric alpha combination present on the document. * Valid character combinations: "1A" through "1Z." * If multiple codes appear present enter the first code combination in the column. * Remove invalid combinations. ### Example: Delete invalid combinations such as "A1" and "11." ### Note: Instructions repeat for all entries on line 14, All 12 Months, (column 2) to Dec (column 14).
Line 15-All 12 monthsEmployee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value CoverageEnter the dollar amount from line 15 column All 12 Months. Enter the amount in dollars only. Enter a single zero if 0 or 00 is present. Blank the field if a negative figure or a negative 0 is present. Use the space bar to a blank field.
Line 15-Jan through Line 15-DecEmployee Required Contribution (see instructions)Enter the dollar amount from line 15 column Jan. Enter the amount in dollars only. Enter a single zero if 0 or 00 is present. Blank the field if a negative figure or a negative 0 is present. Use the space bar for a blank field. ### Note: Instructions repeat for all entries on line 15, All 12 Months, (column 2) to Dec (column 14).
Line 16-All 12 monthsSection 4980H Safe Harbor and Other Relief (enter code, if applicable)Enter the numeric alpha combination present on the document. * Valid character combinations "2A" through "2J." * If multiple codes appear enter the first code combination in the column. * Remove invalid character combinations.
Line 16-Jan through Line 16-DecSection 4980H Safe Harbor and Other Relief (enter code, if applicable)Enter the numeric alpha combination present on the document. * Valid character combinations: "2A" through "2J." * If multiple codes appear enter the first code combination in the column. * Remove invalid character combinations. ### Note: Instructions repeat for all entries on line 16, All 12 Months, (column 2) to Dec (column 14).
Tax Years ≥ 2022 Line 17 All 12 MonthsZIP CodeEnter the five-digit ZIP Code. If blank, incomplete, or illegible press to bypass this field. If too long enter the first five-digits present.
Tax Years ≥ 2022 Line 17-Jan through Line 17-DecZIP CodeEnter the five-digit ZIP Code. If blank, incomplete, or illegible press to bypass this field. If too long enter the first five-digits present. ### Note: If there is an entry in Line 17 All 12 months, DO NOT enter zip code in boxes for Line 17 Jan Dec, press .
OE/DV Screen Prompt Page 3Description Page 3Instructions Form 1095-C, Employer-Provided Health Insurance Offer and Coverage - Page 3
Employer-Provided Self-Insure CoveragePart III If Employer provided self-insured coverage, check the box and enter the information for...Enter "X" if marked.
Line 18(a)-Covered Ind. through Line 30(a)-Covered Ind. First NameCovered individual(s) first nameEnter the first name if present or if you can determine it. If any character in the name is illegible enter a space for the illegible character. Do not leave two consecutive spaces. If it is not possible to determine first, middle initial, and last name place the entire name in last/full name.
Line 18(a)-Covered Ind. through Line 30(a)-Covered Ind. Middle InitialCovered individual(s) middle initialEnter the middle initial if present or if you can determine it.
Line 18(a)-Covered Ind. through Line 30(a)-Covered Ind. Last/Full NameCovered individual(s) last name/full nameEnter the last name. If any character in the name is illegible enter a space for the illegible character. Do not leave two consecutive spaces. If it is not possible to determine first, middle initial, and last name place the entire name in this field. Enter suffixes after the last name entry.
Line 18(b)-SSN or other TIN through Line 30(b)-SSN or other TINSSN or other TINEnter the nine-digit SSN present. * If the SSN is more than nine-digits enter the first nine-digits. * If any digit is illegible or missing enter a period for the illegible or missing digit. ### Exception: If more than 50 percent of the SSNs in the UW appear redacted suspend under Supervisor Request. * If blank, single repeating digit such as 111111111, 222222222, etc., or sequential 123456789 do not enter data. Press . ### Exception: If 50 percent or more of the SSNs in the UW meet the conditions above suspend under Supervisor Request. ### Exception: If name matches line 1 and the SSN is present on line 2 mirror the entry for line 2. ### Caution: Do not enter any data present in columns (b, c, d, or e) if there is no corresponding name present in column (a).
Line 18(c)-DOB through Line 30(c)-DOBDOB (If SSN or other TIN is not available)Enter the date of birth if present in MMDDYYYY format if a complete date is present. ### Caution: If any of one of MM, DD, or YYYY is missing the remaining combination "is not" a DOB. Do not enter partial data in the field. ### Caution: Do not enter any data present in columns (b, c, d, or e) if there is no corresponding name present in column (a).
Line 18(d)-12 Months through Line 30(d)-12 MonthsCovered all 12 monthsEnter "X" if marked. ### Caution: Do not enter any data present in columns (b, c, d, or e) if there is no corresponding name present in column (a).
Line 18(e)-Jan through Line 30(e)-DecMonths of coverage Jan through DecEnter "X" if marked. ### Caution: Do not enter any data present in columns (b, c, d, or e) if there is no corresponding name present in column (a).

Exhibit 3.41.267-7

Valid Characters

OE/DV Screen PromptValid Characters
First Name1. Alphas (A through Z) 2. Numerics (0 through 9) 3. Hyphen (\-) 4. Blank/Space ### Note: Never enter two consecutive spaces. 5. Maximum 35 characters ### Caution: Do not enter other characters even if present on the form.
Middle Initial1. Alphas (A through Z) 2. Maximum 1 character
Last/Full Name1. Alphas (A through Z) 2. Numerics (0 through 9) 3. Hyphen (\-) 4. Blank/Space ### Note: Never enter two consecutive spaces. 5. Ampersand (&) 6. Maximum 35 characters ### Caution: Do not enter other characters even if present on the form.
Address Line1. Alphas (A through Z) 2. Numerics (0 through 9) 3. Hyphen (\-) 4. If blank, enter "Z" 5. Slash (/) 6. Asterisk (\*) only valid in first position for PO Box 7. Space ### Note: Never enter two consecutive spaces. 8. Maximum 35 characters ### Caution: Do not enter other characters even if present on the form.
City Line1. Alphas (A through Z) 2. If blank, enter "ZZZ" 3. Space ### Note: Space for all special characters in the city/state line with except for an apostrophe. Never enter two consecutive spaces and leave no space for the apostrophe. 4. Maximum 25 characters ### Caution: Do not enter other characters even if present on the form.
State Line1. Alphas (A through Z) 2. Blank/Space 3. Maximum 2 characters ### Note: Domestic addresses outweigh foreign addresses in the presence of both.
Province Line1. Alphas (A through Z) 2. Blank/Space 3. Maximum 17 characters ### Note: Domestic addresses outweigh foreign addresses in the presence of both.
ZIP Code1. Numerics (0-9) 2. Space 3. Maximum five or nine numerics ### Reminder: The ZIP Code is consistent with the ZIP Code tables listed in Exhibit 3.41.267-2, Exhibit 3.41.267-3, Exhibit 3.41.267-4, and Exhibit 3.41.267-5.
Country/Foreign postal code1. Alphas (A through Z) 2. Numerics (0-9) 3. Maximum 35 characters ### Reminder: The ZIP Code is consistent with the ZIP Code tables list in Exhibit 3.41.267-2, Exhibit 3.41.267-3, Exhibit 3.41.267-4, and Exhibit 3.41.267-5.
Contact Phone1. Seven, 10 or 12-digits (numbers) 2. Numeric (0-9) 3. Space
Date of Birth (DOB, DOB)1. Numeric (0-9) 2. Format MMDDYYYY 3. Blank/Space
Checkboxes1. Alpha "X" 2. Blank

Exhibit 3.41.267-8

Unit Production Card (UPC) Inputs for Batch/Block Tracking System (BBTS)

SCRIPS Report Number or SourceReport NameIdentifierApplicable Program NumberBBTS Receipts (Yes or No)BBTS Production (Yes or No)
IPS0083Workstation Operator Statistics Program and Function Summary Report460-44320 470-44320 480-44320YesYes
Receipt and Control release to SCRIPSLocal Reports500-44320YesNo
IPS01119Run Balance ReportTotal Records Processed500-44320NoYes
IPS06440Throughput Statistics ReportTotal Documents for all scandrivers minus Total records deleted on IPS01119450-44320YesNo
IPS01119 Total Records ProcessedRun Balance ReportData Records Output450-44320NoYes
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