Designated Government Entity (DGE) Information


Part I - Applicable Large Employer Member (ALE Member)

Line 9: Name of designated Government Entity (only if applicable)
In Line 9, Begin with the complete name of DGE. If you are a DGE filing on behalf of an ALE, use Lines 9-16 to enter the DGE information. If you're NOT a Designated Government Entity (DGE) filing on behalf of an employer, you can skip Lines 9-16.

Line 10: Employer Identification Number (EIN)
In Line 10, enter the EIN of the DGE filing on behalf of the employer. SSN may not be used instead of an EIN. If the DGE does not have an EIN, you can apply for one online at or by mailing or faxing Form SS-4 to the IRS.

Line 11: Street address (including room or suite no.)
Line 12: City or town
Line 13: State or province
Line 14: Country and ZIP or foreign postal code
From Lines 11-14, enter the complete address of the DGE filing for the ALE, including room or suite number, if applicable.

Line 15: Name of person to contact
Line 16: Contact telephone number
In Lines 15 and 16, Enter the name of contact person and telephone number of DGE representative who is responsible for answering any questions about filing Form 1095-C & 1094-C.