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{"sheet":"1095C Template","index":0,"n_rows":6,"n_cols":570,"rows_kept":6,"cut":false,"hidden":false,"merged":[]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"1095 SAMPLE Worksheet for 2022"]
["Name of Employer 1 (Box 7)","Name of Employer 2 (Box 7)","Employer Address 1 (Box 9)","Employer Address 2 (Box 9)","Employer City (Box 11)","Employer State  (Box 12)","Employer Zip (Box 13)","Employer Foreign Address Indicator","Employer Foreign State Name (Box 12)","Employer Foreign Postal Code (Box 13)","Employer Foreign Country Code (Box 13)","1094 Contact First Name","1094 Contact Middle Initial","1094 Contact Last Name","1094 Contact Suffix","1095 Contact Phone (Box 10)","1095 Contact Phone Ext (Box 10)","1094 Contact Phone","1094 Contact Phone Ext","Employer Identification Number (Box 8)","Employer Misc Search One","Employer Misc Search Two","Employee Social Security Number (Box 2)","Employee First Name (Box 1)","Employee Middle Initial (Box 1)","Employee Last Name (Box 1)","Employee Suffix (Box 1)","Employee Address 1 (Box 3)","Employee Address 2 (Box 3)","Employee City (Box 4)","Employee State (Box 5)","Employee Zip (Box 6)","ACA State Filing","Employee Foreign Address Indicator","Employee Foreign State Name (Box 5)","Employee Foreign Postal Code (Box 6)","Employee Foreign Country Code (Box 6)","Employee Email (Online Retrieval)","Employee Misc Search","Employee Age","Plan Start Month","All 12 Month Offer Of Coverage (Line 14)","Jan Offer Of Coverage (Line 14)","Feb Offer Of Coverage (Line 14)","Mar Offer Of Coverage (Line 14)","Apr Offer Of Coverage (Line 14)","May Offer Of Coverage (Line 14)","Jun Offer Of Coverage (Line 14)","Jul Offer Of Coverage (Line 14)","Aug Offer Of Coverage (Line 14)","Sep Offer Of Coverage (Line 14)","Oct Offer Of Coverage (Line 14)","Nov Offer Of Coverage (Line 14)","Dec Offer Of Coverage (Line 14)","Employee Required Contribution For All 12 Months (Line 15)","Employee Required Contribution For Jan (Line 15)","Employee Required Contribution For Feb (Line 15)","Employee Required Contribution For Mar (Line 15)","Employee Required Contribution For Apr (Line 15)","Employee Required Contribution For May (Line 15)","Employee Required Contribution For Jun (Line 15)","Employee Required Contribution For Jul (Line 15)","Employee Required Contribution For Aug (Line 15)","Employee Required Contribution For Sep (Line 15)","Employee Required Contribution For Oct (Line 15)","Employee Required Contribution For Nov (Line 15)","Employee Required Contribution For Dec (Line 15)","Safe Harbor And Other Relief For All 12 Months (Line 16)","Safe Harbor And Other Relief For Jan (Line 16)","Safe Harbor And Other Relief For Feb (Line 16)","Safe Harbor And Other Relief For Mar (Line 16)","Safe Harbor And Other Relief For Apr (Line 16)","Safe Harbor And Other Relief For May (Line 16)","Safe Harbor And Other Relief For Jun (Line 16)","Safe Harbor And Other Relief For Jul (Line 16)","Safe Harbor And Other Relief For Aug (Line 16)","Safe Harbor And Other Relief For Sep (Line 16)","Safe Harbor And Other Relief For Oct (Line 16)","Safe Harbor And Other Relief For Nov (Line 16)","Safe Harbor And Other Relief For Dec (Line 16)","Zip Code For All 12 Months (Line 17)","Zip Code For Jan (Line 17)","Zip Code For Feb (Line 17)","Zip Code For Mar (Line 17)","Zip Code For Apr (Line 17)","Zip Code For May (Line 17)","Zip Code For Jun (Line 17)","Zip Code For Jul (Line 17)","Zip Code For Aug (Line 17)","Zip Code For Sep (Line 17)","Zip Code For Oct (Line 17)","Zip Code For Nov (Line 17)","Zip Code For Dec (Line 17)","Covered Individual Checkbox (Part III)","Individual SSN Or TIN (b1)","DOB (c1)","First Name (a1)","Middle Initial (a1)","Last Name (a1)","Suffix (a1)","Covered 12 Months (d1)","Jan (e1)","Feb (e1)","Mar (e1)","Apr (e1)","May (e1)","Jun (e1)","Jul (e1)","Aug (e1)","Sep (e1)","Oct (e1)","Nov (e1)","Dec (e1)","Individual SSN Or TIN (b2)","DOB (c2)","First Name (a2)","Middle Initial (a2)","Last Name (a2)","Suffix (a2)","Covered 12 Months (d2)","Jan (e2)","Feb (e2)","Mar (e2)","Apr (e2)","May (e2)","Jun (e2)","Jul (e2)","Aug (e2)","Sep (e2)","Oct (e2)","Nov (e2)","Dec (e2)","Individual SSN Or TIN (b3)","DOB (c3)","First Name (a3)","Middle Initial (a3)","Last Name (a3)","Suffix (a3)","Covered 12 Months (d3)","Jan (e3)","Feb (e3)","Mar (e3)","Apr (e3)","May (e3)","Jun (e3)","Jul (e3)","Aug (e3)","Sep (e3)","Oct (e3)","Nov (e3)","Dec (e3)","Individual SSN Or TIN (b4)","DOB (c4)","First Name (a4)","Middle Initial (a4)","Last Name (a4)","Suffix (a4)","Covered 12 Months (d4)","Jan (e4)","Feb (e4)","Mar (e4)","Apr (e4)","May (e4)","Jun (e4)","Jul (e4)","Aug (e4)","Sep (e4)","Oct (e4)","Nov (e4)","Dec (e4)","Individual SSN Or TIN (b5)","DOB (c5)","First Name (a5)","Middle Initial (a5)","Last Name (a5)","Suffix (a5)","Covered 12 Months (d5)","Jan (e5)","Feb (e5)","Mar (e5)","Apr (e5)","May (e5)","Jun (e5)","Jul (e5)","Aug (e5)","Sep (e5)","Oct (e5)","Nov (e5)","Dec (e5)","Individual SSN Or TIN (b6)","DOB (c6)","First Name (a6)","Middle Initial (a6)","Last Name (a6)","Suffix (a6)","Covered 12 Months (d6)","Jan (e6)","Feb (e6)","Mar (e6)","Apr (e6)","May (e6)","Jun (e6)","Jul (e6)","Aug (e6)","Sep (e6)","Oct (e6)","Nov (e6)","Dec (e6)","Individual SSN Or TIN (b7)","DOB (c7)","First Name (a7)","Middle Initial (a7)","Last Name (a7)","Suffix (a7)","Covered 12 Months (d7)","Jan (e7)","Feb (e7)","Mar (e7)","Apr (e7)","May (e7)","Jun (e7)","Jul (e7)","Aug (e7)","Sep (e7)","Oct (e7)","Nov (e7)","Dec (e7)","Individual SSN Or TIN (b8)","DOB (c8)","First Name (a8)","Middle Initial (a8)","Last Name (a8)","Suffix (a8)","Covered 12 Months (d8)","Jan (e8)","Feb (e8)","Mar (e8)","Apr (e8)","May (e8)","Jun (e8)","Jul (e8)","Aug (e8)","Sep (e8)","Oct (e8)","Nov (e8)","Dec (e8)","Individual SSN Or TIN (b9)","DOB (c9)","First Name (a9)","Middle Initial (a9)","Last Name (a9)","Suffix (a9)","Covered 12 Months (d9)","Jan (e9)","Feb (e9)","Mar (e9)","Apr (e9)","May (e9)","Jun (e9)","Jul (e9)","Aug (e9)","Sep (e9)","Oct (e9)","Nov (e9)","Dec (e9)","Individual SSN Or TIN (b10)","DOB (c10)","First Name (a10)","Middle Initial (a10)","Last Name (a10)","Suffix (a10)","Covered 12 Months (d10)","Jan (e10)","Feb (e10)","Mar (e10)","Apr (e10)","May (e10)","Jun (e10)","Jul (e10)","Aug (e10)","Sep (e10)","Oct (e10)","Nov (e10)","Dec (e10)","Individual SSN Or TIN (b11)","DOB (c11)","First Name (a11)","Middle Initial (a11)","Last Name (a11)","Suffix (a11)","Covered 12 Months (d11)","Jan (e11)","Feb (e11)","Mar (e11)","Apr (e11)","May (e11)","Jun (e11)","Jul (e11)","Aug (e11)","Sep (e11)","Oct (e11)","Nov (e11)","Dec (e11)","Individual SSN Or TIN (b12)","DOB (c12)","First Name (a12)","Middle Initial (a12)","Last Name (a12)","Suffix (a12)","Covered 12 Months (d12)","Jan (e12)","Feb (e12)","Mar (e12)","Apr (e12)","May (e12)","Jun (e12)","Jul (e12)","Aug (e12)","Sep (e12)","Oct (e12)","Nov (e12)","Dec (e12)","Individual SSN Or TIN (b13)","DOB (c13)","First Name (a13)","Middle Initial (a13)","Last Name (a13)","Suffix (a13)","Covered 12 Months (d13)","Jan (e13)","Feb (e13)","Mar (e13)","Apr (e13)","May (e13)","Jun (e13)","Jul (e13)","Aug (e13)","Sep (e13)","Oct (e13)","Nov (e13)","Dec (e13)","Individual SSN Or TIN (b14)","DOB (c14)","First Name (a14)","Middle Initial (a14)","Last Name (a14)","Suffix (a14)","Covered 12 Months (d14)","Jan (e14)","Feb (e14)","Mar (e14)","Apr (e14)","May (e14)","Jun (e14)","Jul (e14)","Aug (e14)","Sep (e14)","Oct (e14)","Nov (e14)","Dec (e14)","Individual SSN Or TIN (b15)","DOB (c15)","First Name (a15)","Middle Initial (a15)","Last Name (a15)","Suffix (a15)","Covered 12 Months (d15)","Jan (e15)","Feb (e15)","Mar (e15)","Apr (e15)","May (e15)","Jun (e15)","Jul (e15)","Aug (e15)","Sep (e15)","Oct (e15)","Nov (e15)","Dec (e15)","Individual SSN Or TIN (b16)","DOB (c16)","First Name (a16)","Middle Initial (a16)","Last Name (a16)","Suffix (a16)","Covered 12 Months (d16)","Jan (e16)","Feb (e16)","Mar (e16)","Apr (e16)","May (e16)","Jun (e16)","Jul (e16)","Aug (e16)","Sep (e16)","Oct (e16)","Nov (e16)","Dec (e16)","Individual SSN Or TIN (b17)","DOB (c17)","First Name (a17)","Middle Initial (a17)","Last Name (a17)","Suffix (a17)","Covered 12 Months (d17)","Jan (e17)","Feb (e17)","Mar (e17)","Apr (e17)","May (e17)","Jun (e17)","Jul (e17)","Aug (e17)","Sep (e17)","Oct (e17)","Nov (e17)","Dec (e17)","Individual SSN Or TIN (b18)","DOB (c18)","First Name (a18)","Middle Initial (a18)","Last Name (a18)","Suffix (a18)","Covered 12 Months (d18)","Jan (e18)","Feb (e18)","Mar (e18)","Apr (e18)","May (e18)","Jun (e18)","Jul (e18)","Aug (e18)","Sep (e18)","Oct (e18)","Nov (e18)","Dec (e18)","Individual SSN Or TIN (b19)","DOB (c19)","First Name (a19)","Middle Initial (a19)","Last Name (a19)","Suffix (a19)","Covered 12 Months (d19)","Jan (e19)","Feb (e19)","Mar (e19)","Apr (e19)","May (e19)","Jun (e19)","Jul (e19)","Aug (e19)","Sep (e19)","Oct (e19)","Nov (e19)","Dec (e19)","Individual SSN Or TIN (b20)","DOB (c20)","First Name (a20)","Middle Initial (a20)","Last Name (a20)","Suffix (a20)","Covered 12 Months (d20)","Jan (e20)","Feb (e20)","Mar (e20)","Apr (e20)","May (e20)","Jun (e20)","Jul (e20)","Aug (e20)","Sep (e20)","Oct (e20)","Nov (e20)","Dec (e20)","Individual SSN Or TIN (b21)","DOB (c21)","First Name (a21)","Middle Initial (a21)","Last Name (a21)","Suffix (a21)","Covered 12 Months (d21)","Jan (e21)","Feb (e21)","Mar (e21)","Apr (e21)","May (e21)","Jun (e21)","Jul (e21)","Aug (e21)","Sep (e21)","Oct (e21)","Nov (e21)","Dec (e21)","Individual SSN Or TIN (b22)","DOB (c22)","First Name (a22)","Middle Initial (a22)","Last Name (a22)","Suffix (a22)","Covered 12 Months (d22)","Jan (e22)","Feb (e22)","Mar (e22)","Apr (e22)","May (e22)","Jun (e22)","Jul (e22)","Aug (e22)","Sep (e22)","Oct (e22)","Nov (e22)","Dec (e22)","Individual SSN Or TIN (b23)","DOB (c23)","First Name (a23)","Middle Initial (a23)","Last Name (a23)","Suffix (a23)","Covered 12 Months (d23)","Jan (e23)","Feb (e23)","Mar (e23)","Apr (e23)","May (e23)","Jun (e23)","Jul (e23)","Aug (e23)","Sep (e23)","Oct (e23)","Nov (e23)","Dec (e23)","Individual SSN Or TIN (b24)","DOB (c24)","First Name (a24)","Middle Initial (a24)","Last Name (a24)","Suffix (a24)","Covered 12 Months (d24)","Jan (e24)","Feb (e24)","Mar (e24)","Apr (e24)","May (e24)","Jun (e24)","Jul (e24)","Aug (e24)","Sep (e24)","Oct (e24)","Nov (e24)","Dec (e24)","Individual SSN Or TIN (b25)","DOB (c25)","First Name (a25)","Middle Initial (a25)","Last Name (a25)","Suffix (a25)","Covered 12 Months (d25)","Jan (e25)","Feb (e25)","Mar (e25)","Apr (e25)","May (e25)","Jun (e25)","Jul (e25)","Aug (e25)","Sep (e25)","Oct (e25)","Nov (e25)","Dec (e25)","Reprint Reason"]
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[]
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