State of Alaska

P.O. Box 110203

Juneau, AK 998110203

EDWARD RAIS
617 N ST APT B
ANCHORAGE AK 995013263

Instructions for Recipient Line 8. Continued

A. Small Business Health Options Program (SHOP)
This Form 1095-B provides information about the individuals in your tax family
B. Employer-sponsored coverage
(yourself, spouse, and dependents) who had certain health coverage (referred to
C. Government-sponsored program
as “minimum essential coverage”) for some or all months during the year.
D. Individual market insurance
Minimum essential coverage includes government-sponsored programs, eligible
E . Multiemployer plan
employer-sponsored plans, individual market plans, and other coverage the F . Other designated minimum essential coverage
Department of Health and Human Services designates as minimum essential G . Individual coverage health reimbursement arrangement (HRA)
coverage.
If individuals in your tax family are eligible for certain types of minimum essential If you or another family member received health insurance coverage
coverage, you may not be eligible for the premium tax credit. For more through a Health Insurance Marketplace (also known as an Exchange),
information on the premium tax credit, see Pub. 974, Premium Tax Credit (PTC). that coverage generally will be reported on a Form 1095-A rather than a
Form 1095-B. If you or another family member received employer-sponsored
Providers of minimum essential coverage are required to furnish only one coverage, that coverage may be reported on a Form 1095-C (Part III) rather than a
Form 1095-B for all individuals whose coverage is reported on that form. Form 1095-B. For more information, see www.irs.gov/Affordable-Care-
As the recipient of this Form 1095-B, you should provide a copy to other Act/Questions-and-Answers-About-Health-Care-Information-Forms-for-Individuals.
individuals covered under the policy if they request it for their records.
Line 9. Reserved.
Additional information. For additional information about the tax provisions of the
Affordable Care Act (ACA), including the individual shared responsibility provisions, Part II. Information About Certain Employer-Sponsored Coverage, lines 10–15. If
and the premium tax credit, see www.irs.gov/ACA or call the IRS Healthcare you had employer-sponsored health coverage, this part may provide information
Hotline for ACA questions (800-919-0452). about the employer sponsoring the coverage. This part may show only the last four
digits of the employer’s EIN. This part may also be left blank, even if you had
Part I. Responsible Individual, lines 1–9. Part I reports information about you and employer-sponsored health coverage. If this part is blank, you do not need to fill in
the coverage. the information or return it to your employer or other coverage provider.
Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports
Lines 2 and 3. Line 2 reports your social security number (SSN) or other taxpayer
information about the coverage provider (insurance company, employer providing
identification number (TIN), if applicable. For your protection, this form may show
self-insured coverage, government agency sponsoring coverage under a
only the last four digits. However, the coverage provider is required to report your
government program such as Medicaid or Medicare, or other coverage sponsor).
complete SSN or other TIN, if applicable, to the IRS. Your date of birth will be
Line 18 reports a telephone number for the coverage provider that you can call if
entered on line 3 only if line 2 is blank.
you have questions about the information reported on the form.
Line 8. This is the code for the type of coverage in which you or other covered Part IV. Covered Individuals, lines 23–28. This part reports the name, SSN or other
individuals were enrolled. Only one letter will be entered on this line. TIN, and coverage information for each covered individual. A date of birth will be
entered in column (c) only if the SSN or other TIN is not entered in column (b).
Column (d) will be checked if the individual was covered for at least one day in every
month of the year. For individuals who were covered for some but not all months,
information will be entered in column (e) indicating the months for which these
individuals were covered. If there are more than six covered individuals, see Part IV,
Continuation Sheet(s), for information about the additional covered individuals.

Rev. 11/02/22
 Health Coverage
Form
1095-B ► Do not attach to your tax return. Keep for your records.
Department of the Treasury
Internal Revenue Service ► Go to www.Irs.gov/form1095b for instructions and the latest information. 2022
Part I Responsible Individual
1 Name of responsible individual-First name, middle name, last name 2 Social security number (SSN) or other TIN 3 Date of birth (if SSN or TIN is not available)
EDWARD RAIS 535-50-2809
4 Street address (including apartment no.) 5 City or town 6 State or province 7 Country and ZIP or foreign postal code
617 N ST APT B ANCHORAGE AK 995013263
9 Reserved
8 Enter letter identifying Origin of the Policy (see instructions for codes): . . . . . . . . . ► B
Part II Information About Certain Employer-Sponsored Coverage (see instructions)
10 Employer name 11 Employer identification number (EIN)
State of Alaska 92-0121775
12 Street address (including room or suite no.) 13 City or town 14 State or province 15 Country and ZIP or foreign postal code
P.O. Box 110203 Juneau AK 998110203
Part III Issuer or Other Coverage Provider (see instructions)
16 Name 17 Employer identification number (EIN) 18 Contact telephone number

19 Street address (including room or suite no.) 20 City or town 21 State or province 22 Country and ZIP or foreign postal code

Part IV Covered Individuals (Enter the information for each covered individual(s).
(c) DOB (If SSN (e) Months of Coverage
(a) Name of covered individuals(s) (b) SSN or other (d) Covered all
or other TIN is Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
First name, middle initial, last name TIN 12 months
not available)

23 EDWARD RAIS ***-**-2809 X

24 MARION KELLY ***-**-7595 X

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For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Form 1095-B (2022)