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HEALTH INSURANCE CLAIM FORM

PA

1
2 3 a
MI
DATES

84
NUCC Institution
- MAX
PLEASE PRINT OR TYPE
CAND-0906
1000
17

TFP - ComplyRight CMS-1500 Health Insurance Claim Forms (02/12), 8-1/2" x 11", Pack of 500 (CMS12LC500) - White/Red

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IMPORTANT TAX RETURN DOCUMENT ENCLOSED

3333-1

Certified Fiber SUSTAINABLE Sourcing FORESTRY INITIATIVE www.sfiprogram.org

ComplyRight - Self Seal Security Tinted Double-Window Tax Envelopes, 50/Pack (3333250) - White

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HEALTH INSURANCE CLAIM FORM

PA

1
2 3 a
MI
DATES

84
NUCC Institution
- MAX
PLEASE PRINT OR TYPE
CAND-0906
1000
17

ComplyRight - CMS-1500 Health Insurance Claims, 2500/Pack (CMS12LC) - White/Red

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1096 Department the Treasury Revenue Service
Annual Summary and Transmittal of U.S. Information Returns
No.
FILER'S
address
Room
Country
foreign
Name
contact
number
For Official Use Only
address
number
forms
income tax withheld
Total
this Form
DOX below
type
form
filed.
W-20
1098-C 1098-8
1098-0
1099-A
1099-C
2
16
1099-5
72
5498-QA
27
Return this entire page to the Internal Revenue Service. Photocopies are not acceptable. Send this form, with the copies of the form checked in box 6, to the IRS in a flat mailer (not folded).
Signature
Title
Date
Instructions
Future developments. For the latest information about developments related to Form 1096, such as legislation enacted, go to www.irs.gov/Form1096.
Who must file. Any person or entity who files any form checked in box 6 must file Form 1096 to transmit those

ComplyRight - 2026 1096 Tax Form, 1-Part, Transmittal, 25/Pack (510025) - White/Red/Black

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