PDF-Form B Department of the Treasury Internal Revenue S

irsgovform1095b OMB No 15452252 560115 VOID CORRECTED Part I Responsible Individual Policy Holder 1 Name of responsible individual 2 Social security number SSN 3 Date of birth If SSN is not available 4 Street address including apartment no 5 City or. Attach to Form 990 Information about Schedule F Form 990 and its instructions is at wwwirsgovform990 OMB No 15450047 20 14 Open to Public Inspection Name of the organization Employer identification number Part I General Information on Activities Out irsgovform709 For gifts made during calendar year 2013 See instructions OMB No 15450020 20 13 Part 1General Information 1 Donors first name and middle initial 2 Donors last name 3 Donors social security number 4 Address number street and apartment nu Attach to Form 990 or Form 990EZ Information about Schedule L Form 990 or 990EZ and its instructions is at wwwirsgovform990 OMB No 15450047 20 14 Open To Public Inspection Name of the organization Employer identification number Part I Excess Benefit Attach to Form 990 or 990EZ Information about Schedule O Form 990 or 990EZ and its instructions is at wwwirsgovform990 OMB No 15450047 20 14 Open to Public Inspection Name of the organization Employer identification number For Paperwork Reduction Ac Attach to Form 990 Information about Schedule R Form 990 and its instructions is at wwwirsgovform990 OMB No 15450047 20 14 Open to Public Inspection Name of the organization Employer identification number Part I Identification of Disregarded Entitie Information about Form 2555 and its separate instructions is at wwwirsgovform2555 OMB No 15450074 20 14 Attachment Sequence No 34 For Use by US Citizens and Resident Aliens Only Name shown on Form 1040 Your social security number Part I General Info Information about Schedule 8812 and its separate instructions is at wwwirsgovschedule8812 OMB No 15450074 Attachment Sequence No 47 1040A 1040 8812 1040NR Names shown on return Your social security number Part I Filers Who Have Certain Child Depende Information about Form 2555EZ and its separate instructions is at wwwirsgovform2555ez OMB No 15450074 Attachment Sequence No 34A Name shown on Form 1040 Your social security number You May Use This Form If You Are a US citizen or a resident alien Information about Form 8863 and its separate instructions is at wwwirsgovform8863 OMB No 15450074 20 14 Attachment Sequence No 50 Names shown on return Your social security number CAUTION Complete a separate Part III on page 2 for each student for w For information about Form 8839 and its separate instructions see wwwirsgovform8839 OMB No 15450074 20 14 Attachment Sequence No 38 Names shown on return Your social security number Part I Information About Your Eligible Child or Children You must c Attach to Form 990 or Form 990EZ Information about Schedule L Form 990 or 990EZ and its instructions is at wwwirsgovform990 OMB No 15450047 20 14 Open To Public Inspection Name of the organization Employer identification number Part I Excess Benefit Attach to Form 990 or 990EZ Information about Schedule O Form 990 or 990EZ and its instructions is at wwwirsgovform990 OMB No 15450047 20 14 Open to Public Inspection Name of the organization Employer identification number For Paperwork Reduction Ac Do not sign this form unless all applicable lines have been completed Request may be rejected if the form is incomplete or illegible For more information about Form 4506 visit wwwirsgov/form4506OM US House ofRepresentatives Washington DC 20515 amounts credited cc The Honorable Richard E Neal Chairman House Committee on Ways and Means The Honorable Kevin Brady Ranking Member House Committee on W