- Electronic Form 1095-C
Disclosure & Consent Statement
Please 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...
5.06b Electronic 1095C Disclosure and Consent Form 
