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Electronic 1095C Disclosure and Consent Statement
Handle: Document-84200
Owner: Carrell, Janea (User-136, 05492:EVERETT)DS
Thursday, November 3, 2016 08:59:53 AM PDT
Friday, October 28, 2022 08:47:27 AM PDT
Modified By: Diaz, Ailienette (User-392, 08810:EVERETT)DS
Locked By:
  • Electronic Form 1095-C
Disclosure & Consent StatementPlease send signed consent form to the payroll office.
  • Only those employees who elect to start
receiving electronic Form 1095-C’s need to submit this form.
  • Note: For security reasons, we cannot fax or e-mail 1095-C forms.ey canTh be picked up in the
Payroll Office with proper identification or they can be mailed via the U.S.
  • Postal Service.
  • Once an employee terminates, they will go back to receiving a paper Form 1095-C.
  • 砀 Active district employees must update their mailing address immediately via Employee Online. Employee Name:
(please print)Employee ID#: and La...
Allowed
Debbie Montgomery
Adobe Portable Document Format (.pdf) - application/pdf
5.06b Electronic 1095C Disclosure and Consent Statement 020160725.pdf
No
4
129249
No
Appears In: Payroll
Preferred Version: Electronic 1095C Disclosure and Consent Statement