Line 1: Filer's name
Enter the filer's complete name (that's you).

Line 2: Employer identification number (EIN)
Enter your nine-digit EIN (Employer Identification Number). You cannot substitute another TIN (Tax Identification Number) for an EIN. If you need to apply for one, you can do so online at or by mailing or faxing Form SS-4 to the IRS.

Line 3: Representative's Name (Contact Person)
Enter the name of the person to contact

Line 4: Representative's telephone number
Enter the contact information of the person who is responsible for answering any questions about the Form 1095-B filing.

Line 5: Street address (including room or suite no.)
Line 6: City or town
Line 7: State or province
Line 8: Country and ZIP or foreign postal code

From Lines 5 to 8, Enter the complete address where all correspondence regarding the filing of Form 1095-B may be sent.
A P.O. Box may be entered in lieu of a street address if that's how mail is received by the filer.