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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