Part I - Responsible Individual
Lines 1 to 9 from Part-I of Form 1095-B contain information regarding the responsible individual, or the individual offered the coverage reported in Form 1095-B.
Line 1: name of responsible individual
In Line 1, Begin with the complete name of responsible individual.
Line 2: Social security number
In Line 2, enter the Social Security Number (SSN) of the responsible individual. If the responsible individual has a TIN other than a SSN, the other TIN may be entered instead. If no TIN is available, leave Line 2 blank.
Note: Keep in mind that if the IRS is unable to match this Form 1095-B with the individual's SSN or TIN, they may be unable to determine your compliance with ACA regulations.
Line 3: Date of birth of responsible individual
If a SSN is unavailable for the responsible individual, enter their date of birth (MM/DD/YYYY) on Line 3.
Line 4: Street address (including apartment no)
Line 5: City or town
Line 6: State or province
Line 7: Country and ZIP or foreign postal code
In Lines 4-7, enter the complete mailing address of the responsible individual for the coverage offered. A P.O. Box may be entered in lieu of a street address if that's how mail is received by the individual.