EMPLOYER 1095-C CORRECTION INTAKE
Case number / date received:
Reporting year / ALE member:
Employee internal ID:
Original form version and filing reference:
Disputed field / covered-person row / month:
Employee stated fact:
Authoritative source and reviewer:
Explanation or error?
Source-system correction required:
Original state: draft / furnished only / filed / rejected
Proposed changed fields:
Other affected employees or 1094-C fields:
Approval and applicable correction procedure:
Agency outcome:
Employee furnishing outcome:
Final response / closure date: