CLAY COUNTY SOCIAL SERVICES

INCOME MAINT. UNIT

715 11TH ST. N. #102
MOORHEAD, MN 56560-2042

KALENE M KREBS
______ 1529 34TH AVE S
______ FARGO, ND 58104-6125

Important 2021 Tax Information

You are getting this letter and Form 1095-B because you or members of your household had health care
coverage through Minnesota Health Care Programs (MHCP) during the tax year.
What is Form 1095-B?
Form 1095-B shows the months each person in your household had qualifying health care coverage
through MHCP in 2021.
You may get more than one Form 1095-B if you received MHCP coverage on more than one case
during 2021. Some household members may also get their own Forms 1095-B.
Why is this information important?
If you file a federal tax return, Form 1095-B helps you answer questions about health care coverage
on your federal tax return.
You do not need to send Form 1095-B with your tax return. Keep this form with your tax records.
If you do not file a federal tax return, keep Form 1095-B for your records.
*Important* We send the information on your Form 1095-B to the Internal Revenue Service (IRS).
For each person in your household, make sure the name and Social Security number (SSN) on Form
1095-B match what is listed on the person's Social Security card. The IRS uses each person's name and
SSN to help match the health care coverage information on Form 1095-B with the information you
report on your federal tax return. Corrections you report to us will also be sent to the IRS.
What should I do if I believe the information on my Form 1095-B is incorrect or if I have
questions?
If you believe the information on Form 1095-B is incorrect, or you have questions about the
information on the form, call CLAY COUNTY SOCIAL SERVICES at 218-299-5200. If you have
MinnesotaCare, call Health Care Consumer Support at 651-297-3862 or 800-657-3672.
Where can I get more information?
You can find guidance about the information on Form 1095-B on the back of Form 1095-B under
"Instructions for Recipient."
You can also find more information about the IRS Form 1095-B on the DHS website at
http://mn.gov/dhs/1095B/.

More information on back ====>

 ADA Advisory: For accessible formats of this information or assistance with additional equal access
to human services, write to [email protected], call 800-657-3672, or use your preferred relay
service.

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 Form 1095-B Health Coverage ___ VOID OMB No. 1545-2252

Department of the Treasury ==> Do not attach to your tax return. Keep for your records. ___ CORRECTED 2021
Internal Revenue Service ==> Go to www.irs.gov/Form1095B for instructions and the latest information.
Part I -- Responsible Individual
1 Name of responsible individual - First name, middle name, last name 2 Social security number (SSN) or other TIN 3 Date of birth (if SSN or other TIN is not available)

KALENE M KREBS XXX-XX-8919 12/06/1993

4 Street address (including apartment no.) 5 City or town 6 State or province 7 Country and ZIP or foreign postal code
1529 34TH AVE S FARGO ND USA 58104

9 Reserved
8 Enter letter identifying Origin of the Health Coverage (see instructions for codes): ===> C

Part II -- Information About Certain Employer-Sponsored Coverage (see instructions)

10 Employer name 11 Employer identification number (EIN)

12 Street address (including room or suite no.) 13 City or town 14 State or province 15 Country and ZIP or foreign postal code

Part III -- Issuer or Other Coverage Provider (see instructions)

16 Name 17 Employer identification number (EIN) 18 Contact telephone number
State of Minnesota Department of Human Services 81-3626391 651-297-3862 or 800-657-3672
19 Street address (including room or suite no.) 20 City or town 21 State or province 22 Country and ZIP or foreign postal code
PO Box 64252 St. Paul MN USA 55164

Part IV -- Covered Individuals (Enter the information for each covered individual.)
(a) Name of covered individual(s) (b) SSN or other TIN (c) DOB (if SSN (d) Covered (e) Months of coverage
First name, middle initial, last name or other TIN is all 12
not available) months

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

23 KALENE M KREBS XXX-XX-8919 12/06/1993

X X X X X

24 KYSON T KRAUTER XXX-XX-4915 10/06/2018

X X X X X

25 QUINTON W EVANS XXX-XX-6289 03/01/2013

X X X X X
26

27

28
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60704B Form 1095-B (2021)
24766151 01/05/2022
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Form 1095-B (2021) Page 2

Instructions for Recipient Line 8. This is the code for the type of coverage in which you or other
covered individuals were enrolled. Only one letter will be entered on this line.
This Form 1095-B provides information about the individuals in your tax
family (yourself, spouse, and dependents) who had certain health coverage A. Small Business Health Options Program (SHOP)
(referred to as "minimum essential coverage") for some or all months during B. Employer-sponsored coverage
the year. Minimum essential coverage includes government-sponsored C. Government-sponsored program
programs, eligible employer-sponsored plans, individual market plans, D. Individual market insurance
and other coverage the Department of Health and Human Services E. Multiemployer plan
designates as minimum essential coverage. F. Other designated minimum essential coverage
G. Individual coverage health reimbursement arrangement (HRA)
Before 2019, individuals who did not have minimum essential coverage
and did not qualify for an exemption from this requirement could be liable for ** TIP **If you or another family member received health insurance
the individual shared responsibility payment. Beginning in 2019, individuals coverage through a Health Insurance Marketplace (also known as
will not be responsible for the individual shared responsibility payment an Exchange), that coverage will generally be reported on a
because the payment amount is reduced to $0. However, if individuals in Form 1095-A rather than a Form 1095-B. If you or another family member
your tax family are eligible for certain types of minimum essential coverage, received employer-sponsored coverage, that coverage may be reported on a
you may not be eligible for the premium tax credit. For more information on Form 1095-C (Part III) rather than a Form 1095-B. For more information, see
the premium tax credit, see Pub. 974, Premium Tax Credit (PTC). www.irs.gov/Affordable-Care-Act/Questions-and-Answers-About-Health-
Care-Information-Forms-for-Individuals.
** TIP ** Providers of minimum essential coverage are required to furnish Line 9. Reserved.
only one Form 1095-B for all individuals whose coverage is
reported on that form. As the recipient of this Form 1095-B, you Part II. Information About Certain Employer-Sponsored Coverage, lines
should provide a copy to other individuals covered under the policy if they 10-15. If you had employer-sponsored health coverage, this part may
request it for their records. provide information about the employer sponsoring the coverage. This part
may show only the last four digits of the employer's EIN. This part may also
Additional Information. For additional information about the tax provisions be left blank, even if you had employer-sponsored health coverage. If this
of the Affordable Care Act (ACA), including the individual shared part is blank, you do not need to fill in the information or return it to your
responsibility provisions, and the premium tax credit, see www.irs.gov/ACA employer or other coverage provider.
or call the IRS Healthcare Hotline for ACA questions (800-919-0452).
Part III. Issuer or Other Coverage Provider, lines 16-22. This part reports
Part I. Responsible Individual, lines 1-9. Part I reports information about information about the coverage provider (insurance company, employer
you and the coverage. providing self-insured coverage, government agency sponsoring coverage
under a government program such as Medicaid or Medicare, or other
Lines 2 and 3. Line 2 reports your social security number (SSN) or other coverage sponsor). Line 18 reports a telephone number for the coverage
taxpayer identification number (TIN), if applicable. For your protection, this provider that you can call if you have questions about the information
form may show only the last four digits. However, the coverage provider is reported on the form.
required to report your complete SSN or other TIN, if applicable, to the IRS.
Your date of birth will be entered on line 3 only if line 2 is blank. Part IV. Covered Individuals, lines 23-28. This part reports the name, SSN
or other TIN, and coverage information for each covered individual. A date of
birth will be entered in column (c) only if the SSN or other TIN is not entered in
column (b). Column (d) will be checked if the individual was covered for at
least 1 day in every month of the year. For individuals who were covered
for some but not all months, information will be entered in column (e)
indicating the months for which these individuals were covered. If there are
more than six covered individuals, see Part IV, Continuation Sheet(s), for
information about the additional covered individuals.
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