Tax1095B_V100

OFX / Types / Tax1095B_V100
#TagType
1 SRVRTID ServerIdType
2 TAXYEAR YearType
3 VOID BooleanType
4 CORRECTED BooleanType
5 RESPONSIBLEINDIV anonymous complex type
6 ORIGINOFPOLICYCD anonymous simple type
7 SHOPIDENTIFIER GenericNameType
8 EMPLOYERSPONSORED Employer
9 ISSUERORPROVIDER Employer
10 CONTACTPERSONPHONE PhoneType
11 COVEREDINDIVIDUAL CoveredIndivGrpType
Usages:
XSD
	<xsd:complexType name="Tax1095B_V100">
		<xsd:annotation>
			<xsd:documentation>The OFX element "TAX1095B_V100" is of type "Tax1095B_V100"</xsd:documentation>
		</xsd:annotation>
		<xsd:complexContent>
			<xsd:extension base="ofx:AbstractTaxForm1095">
				<xsd:sequence>
					<xsd:element name="RESPONSIBLEINDIV" minOccurs="0">
						<xsd:annotation>
							<xsd:documentation>The name of the responsible individual on the health plan</xsd:documentation>
						</xsd:annotation>
						<xsd:complexType>
							<xsd:sequence>
								<xsd:choice>
									<xsd:element name="SSN" type="ofx:GenericNameType"/>
									<xsd:element name="BIRTHDATE" type="ofx:DateTimeType">
										<xsd:annotation>
											<xsd:documentation>The date of birth of the responsible individual IF no SSN was provided</xsd:documentation>
										</xsd:annotation>
									</xsd:element>
								</xsd:choice>
								<xsd:element name="NAME" type="ofx:GenericNameType">
									<xsd:annotation>
										<xsd:documentation>First, Middle Intitial, Last name</xsd:documentation>
									</xsd:annotation>
								</xsd:element>
								<xsd:element name="ADDR1" type="ofx:AddressType"/>
								<xsd:element name="ADDR2" type="ofx:AddressType" minOccurs="0"/>
								<xsd:element name="CITY" type="ofx:AddressType"/>
								<xsd:element name="STATE" type="ofx:StateType"/>
								<xsd:element name="POSTALCODE" type="ofx:ZipType"/>
								<xsd:element name="COUNTRYSTRING" type="ofx:CountryStringType" minOccurs="0"/>
							</xsd:sequence>
						</xsd:complexType>
					</xsd:element>
					<xsd:element name="ORIGINOFPOLICYCD" minOccurs="0">
						<xsd:annotation>
							<xsd:documentation>Origin of Policy code from instructions. One of the following: A,B,C,D,E,F</xsd:documentation>
						</xsd:annotation>
						<xsd:simpleType>
							<xsd:restriction base="xsd:string">
								<xsd:length value="1"/>
								<xsd:enumeration value="A"/>
								<xsd:enumeration value="B"/>
								<xsd:enumeration value="C"/>
								<xsd:enumeration value="D"/>
								<xsd:enumeration value="E"/>
								<xsd:enumeration value="F"/>
							</xsd:restriction>
						</xsd:simpleType>
					</xsd:element>
					<xsd:element name="SHOPIDENTIFIER" type="ofx:GenericNameType" minOccurs="0">
						<xsd:annotation>
							<xsd:documentation>The ID of the Small Business Health Options Program (SHOP). If applicable.  
                        </xsd:documentation>
						</xsd:annotation>
					</xsd:element>
					<xsd:element name="EMPLOYERSPONSORED" type="ofx:Employer" minOccurs="0">
						<xsd:annotation>
							<xsd:documentation>Present if Insurance company provides employer-sponsored health coverage. Will be blank if NOT insured employer covereage. </xsd:documentation>
						</xsd:annotation>
					</xsd:element>
					<xsd:element name="ISSUERORPROVIDER" type="ofx:Employer" minOccurs="0">
						<xsd:annotation>
							<xsd:documentation>Provider Information </xsd:documentation>
						</xsd:annotation>
					</xsd:element>
					<xsd:element name="CONTACTPERSONPHONE" type="ofx:PhoneType" minOccurs="0">
						<xsd:annotation>
							<xsd:documentation>Contact phone number for the Coverage Provider who can answer questions regarding the form.</xsd:documentation>
						</xsd:annotation>
					</xsd:element>
					<xsd:element name="COVEREDINDIVIDUAL" type="ofx:CoveredIndivGrpType" minOccurs="0" maxOccurs="unbounded">
						<xsd:annotation>
							<xsd:documentation>Covered individual info</xsd:documentation>
						</xsd:annotation>
					</xsd:element>
				</xsd:sequence>
			</xsd:extension>
		</xsd:complexContent>
	</xsd:complexType>

FDX JSON

{
  "tax1095B" : {
    "taxYear" : 2020,
    "taxFormId" : "e5d4ee73bd1-9295-480f-a426-1095-B",
    "taxFormDate" : "2021-03-30",
    "additionalInformation" : "FDX v4.6",
    "taxFormType" : "Tax1095B",
    "responsibleName" : {
      "first" : "Kris",
      "middle" : "Q",
      "last" : "Public"
    },
    "responsibleTin" : "xxx-xx-1234",
    "responsibleDateOfBirth" : "1995-03-03",
    "responsibleAddress" : {
      "line1" : "1 Main St",
      "city" : "Melrose",
      "state" : "NY",
      "postalCode" : "12121",
      "country" : "US"
    },
    "originOfHealthCoverageCode" : "B",
    "employerNameAddress" : {
      "line1" : "12020 Sunrise Valley Dr",
      "line2" : "Suite 230",
      "city" : "Reston",
      "state" : "VA",
      "postalCode" : "20191",
      "country" : "US",
      "name1" : "Financial Data Exchange"
    },
    "employerTin" : "12-3456789",
    "issuerNameAddress" : {
      "line1" : "1718-1/2 Oak Blvd",
      "city" : "Austin",
      "state" : "TX",
      "postalCode" : "78735",
      "country" : "US",
      "name1" : "American People Health",
      "phone" : {
        "number" : "8885551212"
      }
    },
    "issuerTin" : "99-0011223",
    "coveredIndividuals" : [ {
      "name" : {
        "first" : "Kris",
        "middle" : "Q",
        "last" : "Public"
      },
      "tin" : "xxx-xx-1234",
      "dateOfBirth" : "1995-03-13",
      "coveredAll12Months" : true,
      "coveredMonths" : [ "JAN", "FEB", "MAR", "APR", "MAY", "JUN", "JUL", "AUG", "SEP", "OCT", "NOV", "DEC" ]
    }, {
      "name" : {
        "first" : "Tracy",
        "middle" : "R",
        "last" : "Public"
      },
      "tin" : "xxx-xx-4321",
      "dateOfBirth" : "1995-04-13",
      "coveredAll12Months" : true,
      "coveredMonths" : [ "JAN", "FEB", "MAR", "APR", "MAY", "JUN", "JUL", "AUG", "SEP", "OCT", "NOV", "DEC" ]
    } ]
  }
}

OFX XML

<?xml version="1.0" encoding="UTF-8" standalone="no"?>
<?OFX OFXHEADER="200" VERSION="202" SECURITY="NONE" OLDFILEUID="NONE" NEWFILEUID="NONE"?>

<OFX>
    <SIGNONMSGSRSV1>
        <SONRS>
            <STATUS>
                <CODE>0</CODE>
                <SEVERITY>INFO</SEVERITY>
                <MESSAGE>Successful Login</MESSAGE>
            </STATUS>
            <DTSERVER>39210131000000</DTSERVER>
            <LANGUAGE>ENG</LANGUAGE>
            <FI>
                <ORG>fiName</ORG>
                <FID>fiId</FID>
            </FI>
        </SONRS>
    </SIGNONMSGSRSV1>
    <TAX1095MSGSRSV1>
        <TAX1095TRNRS>
            <TRNUID>_GUID_</TRNUID>
            <STATUS>
                <CODE>0</CODE>
                <SEVERITY>INFO</SEVERITY>
                <MESSAGE>SUCCESS</MESSAGE>
            </STATUS>
            <TAX1095RS>
                <TAX1095B_V100>
                    <SRVRTID>e5d4ee73bd1-9295-480f-a426-1095-B</SRVRTID>
                    <TAXYEAR>2020</TAXYEAR>
                    <RESPONSIBLEINDIV>
                        <SSN>xxx-xx-1234</SSN>
                        <BIRTHDATE>19950303</BIRTHDATE>
                        <NAME>Kris Q Public</NAME>
                        <ADDR1>1 Main St</ADDR1>
                        <CITY>Melrose</CITY>
                        <STATE>NY</STATE>
                        <POSTALCODE>12121</POSTALCODE>
                        <COUNTRYSTRING>US</COUNTRYSTRING>
                    </RESPONSIBLEINDIV>
                    <ORIGINOFPOLICYCD>B</ORIGINOFPOLICYCD>
                    <EMPLOYERSPONSORED>
                        <FEDIDNUMBER>12-3456789</FEDIDNUMBER>
                        <NAME1>Financial Data Exchange</NAME1>
                        <ADDR1>12020 Sunrise Valley Dr</ADDR1>
                        <ADDR2>Suite 230</ADDR2>
                        <CITY>Reston</CITY>
                        <STATE>VA</STATE>
                        <POSTALCODE>20191</POSTALCODE>
                    </EMPLOYERSPONSORED>
                    <ISSUERORPROVIDER>
                        <FEDIDNUMBER>99-0011223</FEDIDNUMBER>
                        <NAME1>American People Health</NAME1>
                        <ADDR1>1718-1/2 Oak Blvd</ADDR1>
                        <CITY>Austin</CITY>
                        <STATE>TX</STATE>
                        <POSTALCODE>78735</POSTALCODE>
                    </ISSUERORPROVIDER>
                    <CONTACTPERSONPHONE>888-555-1212</CONTACTPERSONPHONE>
                    <COVEREDINDIVIDUAL>
                        <PERSONNM>Kris Q Public</PERSONNM>
                        <SSN>xxx-xx-1234</SSN>
                        <PERSONBIRTHDT>19950313</PERSONBIRTHDT>
                        <ALLYEARIND>Y</ALLYEARIND>
                        <JANUARYIND>Y</JANUARYIND>
                        <FEBRUARYIND>Y</FEBRUARYIND>
                        <MARCHIND>Y</MARCHIND>
                        <APRILIND>Y</APRILIND>
                        <MAYIND>Y</MAYIND>
                        <JUNEIND>Y</JUNEIND>
                        <JULYIND>Y</JULYIND>
                        <AUGUSTIND>Y</AUGUSTIND>
                        <SEPTEMBERIND>Y</SEPTEMBERIND>
                        <OCTOBERIND>Y</OCTOBERIND>
                        <NOVEMBERIND>Y</NOVEMBERIND>
                        <DECEMBERIND>Y</DECEMBERIND>
                    </COVEREDINDIVIDUAL>
                    <COVEREDINDIVIDUAL>
                        <PERSONNM>Tracy R Public</PERSONNM>
                        <SSN>xxx-xx-4321</SSN>
                        <PERSONBIRTHDT>19950413</PERSONBIRTHDT>
                        <ALLYEARIND>Y</ALLYEARIND>
                        <JANUARYIND>Y</JANUARYIND>
                        <FEBRUARYIND>Y</FEBRUARYIND>
                        <MARCHIND>Y</MARCHIND>
                        <APRILIND>Y</APRILIND>
                        <MAYIND>Y</MAYIND>
                        <JUNEIND>Y</JUNEIND>
                        <JULYIND>Y</JULYIND>
                        <AUGUSTIND>Y</AUGUSTIND>
                        <SEPTEMBERIND>Y</SEPTEMBERIND>
                        <OCTOBERIND>Y</OCTOBERIND>
                        <NOVEMBERIND>Y</NOVEMBERIND>
                        <DECEMBERIND>Y</DECEMBERIND>
                    </COVEREDINDIVIDUAL>
                </TAX1095B_V100>
            </TAX1095RS>
        </TAX1095TRNRS>
    </TAX1095MSGSRSV1>
</OFX>

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