1095-C Tax Information Request Form

First Name*

Last Name*

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address*

example@example.com

Mailing Address*

Street Address

Street Address Line 2

CityStateZip CodeCountry

Email (electronic – I consent to electronic delivery)U.S. Mail (paper copy to my mailing address above)

Tax Year Being Requested*

Additional Notes

Your information will only be used to fulfill this 1095-C request and will not be shared with third parties.