I authorize ADP TotalSource to electronically sign and file IRS Forms 1094/1095-C Employer-Provided Health Insurance Offer and Coverage on behalf of the ALE Member/FEIN listed on the 1095 Summary tab. I also authorize ADP TotalSource to issue the IRS Form 1095-C to each employee who was a full-time employee for any month of the previous calendar year that has been identified on the 1095 Summary tab. Under penalties of perjury I declare that I have examined these Forms and to the best of my knowledge and belief, they are true, correct and complete. I acknowledge that Forms may be modified by ADP TotalSource based on year-end payroll and benefits data following the date of my acknowledgement.

I acknowledge that if the ALE Member company listed on the 1095 Summary tab terminates its relationship with ADP TotalSource prior to January 31 of the year following the applicable reporting year, the ALE Member company will be responsible for completing and filing the required information returns with the IRS by February 28 if filing on paper (or April 1 if filing electronically), and may be responsible for delivering any required Forms 1095-C to full-time employees no later than January 31.

ADP TotalSource recommends that ALL clients subject to the Employer Shared Responsibility provisions of the Affordable Care Act review and acknowledge their Forms 1094/1095-C. Forms 1094/1095-C that are not acknowledged will be auto acknowledged for print, distribution, and transmission on 2/2/2026. If you do not wish for Forms 1094/1095-C to be auto acknowledged, please select the "I do not authorize" radio button in ART to ensure reporting is not completed.

I authorize ADP TotalSource to electronically sign and file IRS Forms 1094/1095-C Employer-Provided Health Insurance Offer and Coverage on behalf of the ALE Member/FEIN listed on the 1095 Summary tab. I also authorize ADP TotalSource to issue the IRS Form 1095-C to each employee who was a full-time employee for any month of the previous calendar year that has been identified on the 1095 Summary tab. Under penalties of perjury I declare that I have examined these Forms and to the best of my knowledge and belief, they are true, correct and complete. I acknowledge that Forms may be modified by ADP TotalSource based on year-end payroll and benefits data following the date of my acknowledgement.

I acknowledge that if the ALE Member company listed on the 1095 Summary tab terminates its relationship with ADP TotalSource prior to January 31 of the year following the applicable reporting year, the ALE Member company will be responsible for completing and filing the required information returns with the IRS by February 28 if filing on paper (or April 1 if filing electronically), and may be responsible for delivering any required Forms 1095-C to full-time employees no later than January 31.

ADP TotalSource recommends that ALL clients subject to the Employer Shared Responsibility provisions of the Affordable Care Act review and acknowledge their Forms 1094/1095-C. Forms 1094/1095-C that are not acknowledged will be auto acknowledged for print, distribution, and transmission on 2/3/2025. If you do not wish for Forms 1094/1095-C to be auto acknowledged, please select the "I do not authorize" radio button in ART to ensure reporting is not completed.

I authorize ADP TotalSource to electronically sign and file IRS Forms 1094/1095-C Employer-Provided Health Insurance Offer and Coverage on behalf of the ALE Member/FEIN listed on the 1095 Summary tab. I also authorize ADP TotalSource to issue the IRS Form 1095-C to each employee who was a full-time employee for any month of the previous calendar year that has been identified on the 1095 Summary tab. Under penalties of perjury I declare that I have examined these Forms and to the best of my knowledge and belief, they are true, correct and complete. I acknowledge that Forms may be modified by ADP TotalSource based on year-end payroll and benefits data following the date of my acknowledgement.

I acknowledge that if the ALE Member company listed on the 1095 Summary tab terminates its relationship with ADP TotalSource prior to January 31 of the year following the applicable reporting year, the ALE Member company will be responsible for completing and filing the required information returns with the IRS by February 28 if filing on paper (or April 1 if filing electronically), and may be responsible for delivering any required Forms 1095-C to full-time employees no later than January 31.

ADP TotalSource recommends that ALL clients subject to the Employer Shared Responsibility provisions of the Affordable Care Act review and acknowledge their Forms 1094/1095-C. Forms 1094/1095-C that are not acknowledged will be auto acknowledged for print, distribution, and transmission on 2/1/2024. If you do not wish for Forms 1094/1095-C to be auto acknowledged, please select the "I do not authorize" radio button in ART to ensure reporting is not completed.

I authorize ADP TotalSource to electronically sign and file IRS Forms 1094/1095-C Employer-Provided Health Insurance Offer and Coverage on behalf of the ALE Member/FEIN listed on the 1095 Summary tab. I also authorize ADP TotalSource to issue the IRS Form 1095-C to each employee who was a full-time employee for any month of the previous calendar year that has been identified on the 1095 Summary tab. Under penalties of perjury I declare that I have examined these Forms and to the best of my knowledge and belief, they are true, correct and complete. I have read the above statement and acknowledge that once I request to submit, this information may not be modified. Any required modifications will require corrected Forms to be filed.

I acknowledge that if the ALE Member company listed on the 1095 Summary tab terminates its relationship with ADP TotalSource prior to January 31 of the year following the applicable reporting year, the ALE Member company will be responsible for completing and filing the required information returns with the IRS by February 28 if fling on paper (or April 1 if filing electronically), and may be responsible for delivering any required Forms 1095-C to full-time employees no later than January 31.

ADP TotalSource recommends that ALL clients subject to the Employer Shared Responsibility provisions of the Affordable Care Act review and acknowledge their Forms 1095-C and 1094-C. Forms 1095-C that are not acknowledged will be auto acknowledged for print and distribution on 2/1/2023. Forms 1094-C that are not acknowledged will be auto acknowledged for transmission on 2/1/2023. If you do not wish for Forms 1095-C and 1094-C to be auto acknowledged, please select the “I do not authorize” radio button in ART to ensure reporting is not completed.

I authorize ADP TotalSource to electronically sign and file IRS Forms 1094/1095-C Employer-Provided Health Insurance Offer and Coverage on behalf of the ALE Member/FEIN listed on the 1095 Summary tab. I also authorize ADP TotalSource to issue the IRS Form 1095-C to each employee who was a full-time employee for any month of the previous calendar year that has been identified on the 1095 Summary tab. Under penalties of perjury I declare that I have examined these Forms and to the best of my knowledge and belief, they are true, correct and complete. I have read the above statement and acknowledge that once I request to submit, this information may not be modified. Any required modifications will require corrected Forms to be filed.

I acknowledge that if the ALE Member company listed on the 1095 Summary tab terminates its relationship with ADP TotalSource prior to January 31 of the year following the applicable reporting year, the ALE Member company will be responsible for completing and filing the required information returns with the IRS by February 28 if fling on paper (or April 1 if filing electronically), and may be responsible for delivering any required Forms 1095-C to full-time employees no later than January 31.

ADP TotalSource recommends that ALL clients subject to the Employer Shared Responsibility provisions of the Affordable Care Act review and acknowledge their Forms 1095-C and 1094-C. Forms 1095-C that are not acknowledged will be auto acknowledged for print and distribution on 1/20/2022. Forms 1094-C that are not acknowledged will be auto acknowledged for transmission on 1/20/2022. If you do not wish for Forms 1095-C and 1094-C to be auto acknowledged, please select the “I do not authorize” radio button in ART to ensure reporting is not completed.

I authorize ADP TotalSource to electronically sign and file IRS Forms 1094/1095-C Employer-Provided Health Insurance Offer and Coverage on behalf of the ALE Member/FEIN listed on the 1095 Summary tab. I also authorize ADP TotalSource to issue the IRS Form 1095-C to each employee who was a full-time employee for any month of the previous calendar year that has been identified on the 1095 Summary tab. Under penalties of perjury I declare that I have examined these Forms and to the best of my knowledge and belief, they are true, correct and complete. I have read the above statement and acknowledge that once I request to submit, this information may not be modified. Any required modifications will require corrected Forms to be filed.

I acknowledge that if the ALE Member company listed on the 1095 Summary tab terminates its relationship with ADP TotalSource prior to January 31 of the year following the applicable reporting year, the ALE Member company will be responsible for completing and filing the required information returns with the IRS by February 28 if fling on paper (or April 1 if filing electronically), and may be responsible for delivering any required Forms 1095-C to full-time employees no later than January 31.

I authorize ADP TotalSource to electronically sign and file IRS Forms 1094/1095-C Employer-Provided Health Insurance Offer and Coverage on behalf of the ALE Member/FEIN listed on the 1095 Summary tab. I also authorize ADP TotalSource to issue the IRS Form 1095-C to each employee who was a full-time employee for any month of the previous calendar year that has been identified on the 1095 Summary tab. Under penalties of perjury I declare that I have examined these Forms and to the best of my knowledge and belief, they are true, correct and complete. I have read the above statement and acknowledge that once I request to submit, this information may not be modified. Any required modifications will require corrected Forms to be filed.

I acknowledge that if the ALE Member company listed on the 1095 Summary tab terminates its relationship with ADP TotalSource prior to January 31 of the year following the applicable reporting year, the ALE Member company will be responsible for completing and filing the required information returns with the IRS by February 28 if fling on paper (or April 1 if filing electronically), and may be responsible for delivering any required Forms 1095-C to full-time employees no later than January 31.

I authorize ADP TotalSource to electronically sign and file IRS Forms 1094/1095-C Employer-Provided Health Insurance Offer and Coverage on behalf of the ALE Member/FEIN listed on the 1095 Summary tab. I also authorize ADP TotalSource to issue the IRS Form 1095-C to each employee who was a full-time employee for any month of the previous calendar year that has been identified on the 1095 Summary tab. Under penalties of perjury I declare that I have examined these Forms and to the best of my knowledge and belief, they are true, correct and complete. I have read the above statement and acknowledge that once I request to submit, this information may not be modified. Any required modifications will require corrected Forms to be filed.

I acknowledge that if the ALE Member company listed on the 1095 Summary tab terminates its relationship with ADP TotalSource prior to January 31 of the year following the applicable reporting year, the ALE Member company will be responsible for completing and filing the required information returns with the IRS by February 28 if fling on paper (or April 1 if filing electronically), and may be responsible for delivering any required Forms 1095-C to full-time employees no later than January 31.

I authorize ADP TotalSource to electronically sign and file IRS Forms 1094/1095-C Employer-Provided Health Insurance Offer and Coverage on behalf of the ALE Member/FEIN listed on the 1095 Summary tab. I also authorize ADP TotalSource to issue the IRS Form 1095-C to each employee who was a full-time employee for any month of the previous calendar year that has been identified on the 1095 Summary tab. Under penalties of perjury I declare that I have examined these Forms and to the best of my knowledge and belief, they are true, correct and complete. I have read the above statement and acknowledge that once I request to submit, this information may not be modified. Any required modifications will require corrected Forms to be filed.

I acknowledge that if the ALE Member company listed on the 1095 Summary tab terminates its relationship with ADP TotalSource prior to March 2 of the year following the applicable reporting year, the ALE Member company will be responsible for completing and filing the required information returns with the IRS by February 28 if fling on paper (or April 2 if filing electronically), and may be responsible for delivering any required Forms 1095-C to full-time employees no later than March 2.

I authorize ADP TotalSource to electronically sign and file IRS Forms 1094/1095-C Employer-Provided Health Insurance Offer and Coverage on behalf of the ALE Member/FEIN listed on the 1095 Summary tab. I also authorize ADP TotalSource to issue the IRS Form 1095-C to each employee who was a full-time employee for any month of the previous calendar year that has been identified on the 1095 Summary tab. Under penalties of perjury I declare that I have examined these Forms and to the best of my knowledge and belief, they are true, correct and complete. I have read the above statement and acknowledge that once I request to submit, this information may not be modified. Any required modifications will require corrected Forms to be filed.

I acknowledge that if the ALE Member company listed on the 1095 Summary tab terminates its relationship with ADP TotalSource prior to January 31 of the year following the applicable reporting year, the ALE Member company will be responsible for completing and filing the required information returns with the IRS by February 28, 2017 if filing on paper (or March 31 if filing electronically), and may be responsible for delivering any required Forms 1095-C to full-time employees no later than March 2.

I authorize ADP TotalSource to electronically sign and file IRS Forms 1094/1095-C Employer-Provided Health Insurance Offer and Coverage on behalf of the ALE Member/FEIN listed on the 1095 Summary tab. I also authorize ADP TotalSource to issue the IRS Form 1095-C to each employee who was a full-time employee for any month of the previous calendar year that has been identified on the 1095 Summary tab. Under penalties of perjury I declare that I have examined these Forms and to the best of my knowledge and belief, they are true, correct and complete. I have read the above statement and acknowledge that once I request to submit, this information may not be modified. Any required modifications will require corrected Forms to be filed.

I acknowledge that if the ALE Member company listed on the 1095 Summary tab terminates its relationship with ADP TotalSource prior to January 31 of the year following the applicable reporting year, the ALE Member company will be responsible for completing and filing the required information returns with the IRS by May 31, 2016 if filing on paper (or June 30 if filing electronically), and may be responsible for delivering any required Forms 1095-C to full-time employees no later than March 31.