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

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

KB14-071

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 Subject:  IMPORTANT TAX RETURN DOCUMENT AVAILABLE

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

The following text is an example only for a PDF consent form.

If you would like to receive your 1095-C by e-mail, you must reply to this message and place the following text in your reply:

“I agree to accept my 1095-C statement electronically at this e-mail address.” (Or, you may specify a different e-mail address).

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.”

Please note you will receive a paper copy of your 1095-C unless you specify differently prior to 01/15/2013.  Consent is for one year only and consent will be required again next year.

You may revoke your consent for an electronic 1095-C delivery prior to January 15, 2018 by contacting the payroll department at w2consent@fabrikam.com or at 555-555-5555, ext. 555.  Withdrawing consent by January 15, 2018 will be for this year only and does not apply to any 1095-C documents you have already received.
Conditions under which 1095-Cs will no longer be furnished electronically may include:
(List all reasons – for example, termination of employment).

E-Mail addresses used for electronic delivery may be changed prior to January 15, 2018 by contacting the payroll department at w2consent@fabrikam.com or at 555-555-5555, ext. 555.

When you receive your 1095-C electronically, it will be attached to an e-mail as a PDF file – much like the one you are currently reading.  You will need PDF reading software (such as Adobe Acrobat Reader) and the hardware necessary to run the PDF reader software.  If you are reading this on your own computer after having opened this attached via your e-mail then you meet the hardware and software requirements for receiving your electronic 1095-C.

Questions / Resources

If you have questions or comments please email Support@integrity-data.com.

If you would like to search for information and resources for Integrity Data products check out the following sites

Last Review: 12/29/2017 – Revision: 1.0

Applies To: ACA Compliance Solution

Categories:  Year End – 1095-C and Filing

Keywords: E-Mail, Consent, 1095-C

2017-12-29T07:53:19+00:00December 29th, 2017|0 Comments

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