This is a Form 1095-B for the year 2017, issued by the Department of the Treasury, Internal Revenue Service. It provides information about health coverage for individuals. The form is largely unfilled, with empty fields for the responsible individual's name, SSN, and address, as well as for employer and issuer information. The form includes a table for covered individuals, but it is mostly empty or marked with placeholders.
documents/EFTA01222589.pdf
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