
Form 4423 
Application for Filing Affordable Care Act (ACA) Information Returns
(March 2016)

Cat. No. 66481T

Provided by the:
Internal Revenue Service
Alternative Media Center

In 1 File
Print pages 1-3

Contents

Section:  Page
Form 4423:  1
Instructions for Form 4423, Application for Filing Affordable Care Act (ACA) Information Returns:  2
Specific Instructions:  2

This electronic edition contains the entire text of the print edition.

<page 1>

Form 4423
Application for Filing Affordable Care Act (ACA) Information Returns
(March 2016)
IRS Use Only: ----

1. Please check the box that applies to this application
   -- New application
   -- Revised application
2. Is the request for a Foreign Filer
   -- Yes
   -- No
3. Software developers, transmitter and/or issuer information
   Legal name: ----
   Doing Business As (DBA) name: ----
   Telephone number (include country code if applicable): ----
   Business type (check only one box)
      -- Association
      -- Corporation
      -- Credit Union
      -- Federal Government Agency
      -- Limited Liability Corporation
      -- Limited Liability Partnership
      -- Local Government Agency
      -- Partnership
      -- Personal Service Corporation
      -- Sole-Proprietorship
      -- State Government Agency
      -- Volunteer Organization
   Mailing address: ----
   City or town: ----
   State or province: ----
   Country: ----
   ZIP or foreign postal code: ----
   Business address (if different than mailing address): ----
   City or town: ----
   State or province: ----
   Country: ----
   ZIP or foreign postal code: ----
4. Responsible Official Information (at least two)
   Name (first, middle initial, last): ----
   Name suffix: ----
   Position or title: ----
   U.S. citizenship
      -- Yes
      -- No
      -- Legal resident alien
   Social Security/ITIN Number: ----
   Date of Birth (mm/dd/yyyy): ----
   Email address: ----
   Telephone number: ----
   Name (first, middle initial, last): ----
   Name suffix: ----
   Position or title: ----
   U.S. citizenship
      -- Yes
      -- No
      -- Legal resident alien
   Social Security/ITIN Number: ----
   Date of Birth (mm/dd/yyyy): ----
   Email address: ----
   Telephone number: ----
5. Contact Information (At least two, no more than 10)
   Name (first, middle initial, last): ----
   Position or title: ----
   U.S. citizenship
      -- Yes
      -- No
      -- Legal resident alien
   Social Security/ITIN Number: ----
   Email address: ----
   Telephone number: ----
   Name (first, middle initial, last): ----
   Position or title: ----
   U.S. citizenship
      -- Yes
      -- No
      -- Legal resident alien
   Social Security/ITIN Number: ----
   Email address: ----
   Telephone number: ----
6. Forms applying for (check all that apply)
   -- 1094/1095-B
   -- 1094/1095-C
7. Role (check all that apply)
   -- Transmitter
   -- Software Developer
   -- Issuer
8. Transmission method
   -- A2A
   -- User Interface

Under penalties of perjury, I declare that I have examined this document, including any accompanying statements, and to the best of my knowledge and belief, it is true, correct and complete.

9. Responsible Official
   Name: ----
   Title: ----
   Signature (a computer generated signature is not acceptable): ----
   Date: ----
   Name: ----
   Title: ----
   Signature (a computer generated signature is not acceptable): ----
   Date: ----

<page 2>

Instructions for Form 4423, Application for Filing Affordable Care Act (ACA) Information Returns

Purpose of Form. If you are a foreign organization without an Employer Identification Number (EIN) and you need to request authorization for a Transmitter Control Code (TCC) to act as a Transmitter or Software Developer for electronic filing of Form 1094-B, Transmittal of Health Coverage Information Returns and Form 1095-B, Health Coverage; and/or Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns and Form 1095-C, Employer-Provided Health Insurance Offer and Coverage.

This form may also be used to update an existing application for an organization without an EIN. Do not submit this form if you are eligible for, or if you have an EIN assigned by the IRS. Applicants with an EIN must submit their Affordable Care Act Information Return Application electronically on www.irs.gov using e-services  online for tax professionals.

Specific Instructions

Due Date: Submit Form 4423 at least 45 days before the due date of the return you will be filing electronically. See Publication 5164 for information on required testing that must be completed prior to filing.

Block 1

Check the "New application" box for an initial request of a TCC. Check the "Revised application" box when adding, deleting or changing any information on the ACA Application. This box should also be checked when additional roles are needed.

Block 2

For the purposes of this form, a foreign filer is a nonresident alien individual, foreign corporation, foreign partnership, foreign trust, foreign estate, and/or any, other foreign entity who is not a U.S. person that is required to electronically file ACA Information Returns.

Block 3  Software Developers, Transmitter and/or Issuer Information

 Enter the legal name associated with the organization that will write origination or transmission software (software developer), or submit the electronic files (transmitter and/or Issuer).
 Enter a "Doing Business As" (DBA) name if, for the purpose of IRS electronic filing, your business uses a name other than the legal name.
 Enter the 10 digit telephone number, including the appropriate country code for international calls.
 Check the type of entity box which describes your organization. If your entity type is not listed here, select the type that most closely matches your organizational structure.
 Enter the complete mailing address for your organization including: street address and number, city or town, state or province, Country, Zip or Foreign Postal Code.
 Enter the physical address for your organization if different from the mailing address.

Block 4  Responsible Official Information

For the purposes of this form, a Responsible Official is an individual responsible for electronic filing operation at a location with authority to act for the organization in legal and/or tax matters over the business. This individual is the first point of contact with the IRS, and has authority to sign a new or revised ACA information returns application. Responsible Officials must have attained the age of 18 as of the date of the application. Each application must have two Responsible Officials.

 Enter the complete name (first, middle initial and last) and appropriate suffix, if applicable.
 Enter the Responsible Official's position or title with the company.
 Check the appropriate U.S. citizenship status box.
 Enter the Responsible Official's social security number or ITIN, if applicable.
 Enter the Responsible Official's date of birth using the format MMDDYYYY.
 Enter the Responsible Official's email address.
 Enter the Responsible Official's 10 digit telephone number, including the appropriate country code for international calls.

Block 5  Contact Information

For the purposes of this form, a Contact is an individual who is available on a daily basis for the IRS to contact with general questions during testing and the processing year. Each application must have at least two, but no more than ten contacts.

 Enter the complete name (first, middle initial, and last) and appropriate suffix, if applicable.
 Enter the Contact's position or title with the company.
 Check the appropriate U.S. citizenship status box.
 Enter the Contact's social security number or ITIN, if applicable.
 Enter the Contact's date of birth using the format MMDDYYYY.
 Enter the Contact's email address.
 Enter the Contact's 10 digit telephone number, including the appropriate country code for international calls.

<page 3>

Block 6  Forms

Indicate the forms you will be filing electronically with this TCC. Check all box(es) that apply

Form 1094-B, Transmittal of Health Coverage Information Returns
Form 1095-B, Health Coverage
Form 1094-C, Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns
Form 1095-C, Employer-Provided Health Insurance Offer and Coverage

Please be sure to submit your electronic files using the correct TCC. For further information concerning the electronic filing of ACA information returns access www.irs.gov for the current tax year publications.

Block 7  Role

Check all box(es) that apply

Transmitter: A third-party that directly sends the electronic return data to the IRS on behalf of any business that is required to file.
Software Developer: Writes either origination or transmission software according to the IRS specifications.
Note: If the Software Developer box is checked the following fields must be completed  Package Type, Tax Year, Package Name, Website, Forms and Transmission Method, Software Contact, Email Address and Telephone.
Issuer: A business that is required to file ACA information returns.

Block 8  Transmission method

Check all box(es) that apply. For more information on the transmission methods, see Publication 5165, Guide for Electronically Filing Affordable Care Act (ACA) Information Returns for Software Developers and Transmitters.

ISS-A2A  System Enroller: Involves a machine-to-machine process that allows Transmitters/Issuers to create XML and send to the IRS as simple object access protocol (SOAP) message.
ISS-UI for ACA Internet Transmitter: A web user interface that allows Transmitters/Issuers to file forms with the IRS and check submission status.

Block 9

The form must be signed and dated by each responsible official of the company or organization requesting authorization to report electronically.

Mailing Address

Send your Form 4423 to the address below:

Internal Revenue Service
230 Murall Drive Mail Stop 4360
Kearneysville, WV 25430

If you prefer, Form 4423 can be faxed to the IRS at (877) 477-0572 from within the U.S. or (304) 579-4105 from outside the U.S.

You may contact the IRS at (866) 937-4130 from within the U.S. or (470) 769-5100 from outside the U.S., Monday through Friday.

We will not issue a TCC over the phone or by email. If you do not receive a reply from IRS within 45 days, contact us at the telephone number shown above. Do not submit any files until you receive your TCC.

Privacy Act and Paperwork Reduction Act Notice

We ask for the information on this form to carry out the Internal Revenue laws of the United States.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103.

The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is:

Preparing, copying and sending the form to the IRS: 20 min.

You can send us comments from www.irs.gov/formspubs. Click on More Information and then click on Give us feedback. Or you can send your comments to the Internal Revenue Service, Tax Forms and Publications Division, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Do not send the form to this address.

End of Form 4423
