type, category, person, date, source
| type |
category |
person |
date |
source |
| 1095c |
tax |
Xuewei Jiang |
2018-12-31 |
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 |