type, category, person, date, source
type
category
person
date
source
tax-form
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