Tax Documents
Tax1095C
FDX / Data Structures / Tax1095C
Form 1095-C, Employer-Provided Health Insurance Offer and Coverage
Extends and inherits all fields from Tax
Tax1095C Properties
| # | Id | Type | Description |
|---|---|---|---|
| 1 | employeeName | IndividualName | Box 1, Employee name |
| 2 | tin | string | Box 2, Social security number (SSN) |
| 3 | employeeAddress | Address | Boxes 3-6, Employee address |
| 4 | employerNameAddress | NameAddressPhone | Boxes 7, 9-13, Employer name, address and phone |
| 5 | employerTin | string | Box 8, Employer identification number (EIN) |
| 6 | selfInsuredCoverage | boolean | Self Insured Coverage |
| 7 | offersOfCoverage | Array of OfferOfHealthInsuranceCoverage | Boxes 14-16, Employee Offer of Coverage |
| 8 | employeeAge | integer | Employee's Age on January 1 |
| 9 | planStartMonth | integer | Plan Start Month |
| 10 | coveredIndividuals | Array of HealthInsuranceCoveredIndividual | Boxes 17+, Covered Individuals |
Tax1095C Usage:
- TaxData tax1095C
FDX Data Structure as JSON
{
"tax1095C" : {
"taxYear" : 0,
"corrected" : true,
"accountId" : "",
"taxFormId" : "",
"taxFormDate" : "2020-07-01",
"description" : "string",
"additionalInformation" : "string",
"taxFormType" : "BusinessIncomeStatement",
"attributes" : [ {
"name" : "string",
"value" : "string",
"boxNumber" : "string",
"code" : "string"
} ],
"error" : {
"code" : "string",
"message" : "string"
},
"employeeName" : {
"first" : "string",
"middle" : "string",
"last" : "string",
"suffix" : "string"
},
"tin" : "string",
"employeeAddress" : {
"line1" : "String64",
"line2" : "String64",
"line3" : "String64",
"city" : "String64",
"state" : "String64",
"postalCode" : "string",
"country" : "AD"
},
"employerNameAddressPhone" : {
"line1" : "String64",
"line2" : "String64",
"line3" : "String64",
"city" : "String64",
"state" : "String64",
"postalCode" : "string",
"country" : "AD",
"name1" : "String64",
"name2" : "String64",
"phone" : {
"type" : "HOME",
"country" : "string",
"number" : "string",
"extension" : "string"
}
},
"employerNameAddress" : {
"line1" : "String64",
"line2" : "String64",
"line3" : "String64",
"city" : "String64",
"state" : "String64",
"postalCode" : "string",
"country" : "AD",
"name1" : "String64",
"name2" : "String64",
"phone" : {
"type" : "HOME",
"country" : "string",
"number" : "string",
"extension" : "string"
}
},
"employerId" : "string",
"employerTin" : "string",
"selfInsuredCoverage" : true,
"offersOfCoverage" : [ {
"coverageCode" : "string",
"requiredContribution" : 0.0,
"section4980HCode" : "string",
"postalCode" : "string",
"month" : "ANNUAL"
} ],
"employeeAge" : 0,
"planStartMonth" : 0,
"coveredIndividuals" : [ {
"name" : {
"first" : "string",
"middle" : "string",
"last" : "string",
"suffix" : "string"
},
"tin" : "string",
"dateOfBirth" : "2020-07-01",
"coveredAt12Months" : true,
"coveredMonths" : [ "JAN" ]
} ]
}
}
Example Form PDF
Example Form JSON
{
"tax1095C" : {
"taxYear" : 2022,
"taxFormId" : "e5d4ee73bd1-9295-480f-a426-1095-C",
"taxFormDate" : "2021-03-30",
"taxFormType" : "Tax1095C",
"employeeName" : {
"first" : "Kris",
"middle" : "Q",
"last" : "Public"
},
"tin" : "xxx-xx-1234",
"employeeAddress" : {
"line1" : "1 Main St",
"city" : "Melrose",
"state" : "NY",
"postalCode" : "12121",
"country" : "US"
},
"employerNameAddress" : {
"line1" : "12021 Sunset Valley Dr",
"line2" : "Suite 230",
"city" : "Preston",
"state" : "VA",
"postalCode" : "20191",
"country" : "US",
"name1" : "Tax Form Issuer, Inc",
"phone" : {
"number" : "8885551212"
}
},
"employerTin" : "12-3456789",
"selfInsuredCoverage" : false,
"offersOfCoverage" : [ {
"coverageCode" : "1E",
"requiredContribution" : 15.09,
"section4980HCode" : "2C",
"postalCode" : "12121",
"month" : "NOVEMBER"
}, {
"coverageCode" : "1E",
"requiredContribution" : 15.09,
"section4980HCode" : "2C",
"postalCode" : "12121",
"month" : "DECEMBER"
}, {
"coverageCode" : "1E",
"requiredContribution" : 30.18,
"section4980HCode" : "2C",
"postalCode" : "12121",
"month" : "ANNUAL"
} ],
"employeeAge" : 25,
"planStartMonth" : 11,
"coveredIndividuals" : [ {
"name" : {
"first" : "Kris",
"middle" : "Q",
"last" : "Public"
},
"tin" : "xxx-xx-1234",
"dateOfBirth" : "1995-07-11",
"coveredAll12Months" : true,
"coveredMonths" : [ "NOV", "DEC" ]
}, {
"name" : {
"first" : "Tracy",
"middle" : "R",
"last" : "Public"
},
"tin" : "xxx-xx-4321",
"dateOfBirth" : "1995-08-11",
"coveredAll12Months" : true,
"coveredMonths" : [ "NOV", "DEC" ]
} ]
}
}
Example Form JSON for QR Code Purposes
Example Data As Flattened Map (Key, Value Pairs)
{
"taxYear": "2022",
"taxFormId": "e5d4ee73bd1-9295-480f-a426-1095-C",
"taxFormDate": "2021-03-30",
"taxFormType": "Tax1095C",
"employeeName.first": "Kris",
"employeeName.middle": "Q",
"employeeName.last": "Public",
"tin": "xxx-xx-1234",
"employeeAddress.line1": "1 Main St",
"employeeAddress.city": "Melrose",
"employeeAddress.state": "NY",
"employeeAddress.postalCode": "12121",
"employeeAddress.country": "US",
"employerNameAddress.line1": "12021 Sunset Valley Dr",
"employerNameAddress.line2": "Suite 230",
"employerNameAddress.city": "Preston",
"employerNameAddress.state": "VA",
"employerNameAddress.postalCode": "20191",
"employerNameAddress.country": "US",
"employerNameAddress.name1": "Tax Form Issuer, Inc",
"employerNameAddress.phone.number": "8885551212",
"employerTin": "12-3456789",
"selfInsuredCoverage": "false",
"offersOfCoverage-1.coverageCode": "1E",
"offersOfCoverage-1.requiredContribution": "15.09",
"offersOfCoverage-1.section4980HCode": "2C",
"offersOfCoverage-1.postalCode": "12121",
"offersOfCoverage-1.month": "NOVEMBER",
"offersOfCoverage-2.coverageCode": "1E",
"offersOfCoverage-2.requiredContribution": "15.09",
"offersOfCoverage-2.section4980HCode": "2C",
"offersOfCoverage-2.postalCode": "12121",
"offersOfCoverage-2.month": "DECEMBER",
"offersOfCoverage-3.coverageCode": "1E",
"offersOfCoverage-3.requiredContribution": "30.18",
"offersOfCoverage-3.section4980HCode": "2C",
"offersOfCoverage-3.postalCode": "12121",
"offersOfCoverage-3.month": "ANNUAL",
"employeeAge": "25",
"planStartMonth": "11",
"coveredIndividuals-1.name.first": "Kris",
"coveredIndividuals-1.name.middle": "Q",
"coveredIndividuals-1.name.last": "Public",
"coveredIndividuals-1.tin": "xxx-xx-1234",
"coveredIndividuals-1.dateOfBirth": "1995-07-11",
"coveredIndividuals-1.coveredAll12Months": "true",
"coveredIndividuals-1.coveredMonths-1": "NOV",
"coveredIndividuals-1.coveredMonths-2": "DEC",
"coveredIndividuals-2.name.first": "Tracy",
"coveredIndividuals-2.name.middle": "R",
"coveredIndividuals-2.name.last": "Public",
"coveredIndividuals-2.tin": "xxx-xx-4321",
"coveredIndividuals-2.dateOfBirth": "1995-08-11",
"coveredIndividuals-2.coveredAll12Months": "true",
"coveredIndividuals-2.coveredMonths-1": "NOV",
"coveredIndividuals-2.coveredMonths-2": "DEC"
}
Issuer Instructions
