---
type: 1095c
category: tax
person: Xuewei Jiang
date: 2018-12-31
source: jiang_1095c_2018.pdf
---

# Form 1095-C - Employer-Provided Health Insurance (2018)

## Part I - Employee

| Field | Value |
|---|---|
| 1. Name | Xuewei Jiang |
| 2. SSN | ***-**-3215 |
| 3. Address | 2110 Speedway Stop B6600, CBA 6.222 |
| 4. City/State/ZIP | Austin, TX 78712-1276 |

## Applicable Large Employer Member (Employer)

| Field | Value |
|---|---|
| 7. Name | The University of Texas at Austin |
| 8. EIN | 746000203 |
| 9. Address | 1616 Guadalupe St., Suite 1.408 |
| 10. Phone | (512) 471-4772 |
| 11. City/State/ZIP | Austin, TX 78701 |

## Part II - Employee Offer of Coverage

| Field | Value |
|---|---|
| 14. Offer of Coverage (All 12 Months) | 1G |
| 15. Employee Required Contribution | (blank for all months) |
| 16. Section 4980H Safe Harbor | (blank) |

Code 1G: Not a full-time employee for any month but enrolled in self-insured employer-sponsored coverage.

## Part III - Covered Individuals

Self-insured coverage: Yes (checked)

| Name | SSN | Covered All 12 Months |
|---|---|---|
| Xuewei Jiang | ***-**-3215 | X |