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Sample Employee E-Mail and PDF Consent Form for 1095-C

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Sample E-Mail

The following e-mail is an example only and uses the disclosure requirements set forth in IRS Publication 15a and Treasury Regulations Sub Chapter  C. Sec 31.6051-1(j).


Email Body:

Fabrikam is pleased to offer 1095-C statements via e-mail this year instead of the traditional paper copy! Benefits to receiving your 1095-C by e-mail are:
(List all benefits – link to list of benefits below).

Please read the attached PDF file for instructions on how to consent to this process and for important information regarding electronic delivery of your 1095-C.  If you are unable to read the attached PDF file, please contact … or download … (with link)

You may decline the electronic 1095-C and continue to receive a paper copy of your 1095-C by either not replying or by replying and stating:

“I do not want to receive my 1095-C electronically.”

Sample PDF Consent Form

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