To request a duplicate Form 1095, make corrections to your Form 1095, or to ask questions related to ACA requirements, enter the requested information below. When completed, press the button "Submit to ACA Team". Your information will be automatically forwarded. The Form 1095 will be mailed on or before the ACA-required deadline of March 4, 2019. *Response required What was your Status during the Reporting Year? * Active State Employee Retired/COBRA Covered Former Employee Department/Agency * - Select -ADMINISTRATIVE SERVICESAGRICULTURE AND LAND STEWARDSHIPALCOHOLIC BEVERAGESATTORNEY GENERALAUDITOR OF STATEBANKINGBOARD OF EDUCATIONAL EXAMINERSBOARD OF REGENTS (Board Members Only)CIVIL RIGHTS COMMISSIONCOLLEGE AIDCONSUMER ADVOCATECORRECTIONS - ANAMOSACORRECTIONS - CENTRAL OFFICECORRECTIONS - CLARINDACORRECTIONS - FARM ACCOUNTCORRECTIONS - FORT DODGECORRECTIONS - FORT MADISONCORRECTIONS - INDUSTRIESCORRECTIONS - IOWA MEDICAL AND CLASSIFICATIONCORRECTIONS - MITCHELLVILLECORRECTIONS - MT PLEASANTCORRECTIONS - NEWTONCORRECTIONS - ROCKWELL CITYCREDIT UNIONCULTURAL AFFAIRSDEPT FOR THE BLINDDEPT OF MANAGEMENTDEPT OF TRANSPORTATIONEDUCATIONETHICS AND CAMPAIGN DISCLOSURE BOARDFINANCE AUTHORITYGOV OFFICE ON DRUG CONTROL POLICYGOVERNOR'S OFFICEHOMELAND SECURITY AND EMERGENCY MANAGEMENTHUMAN RIGHTSHUMAN SERVICES - ADMINISTRATIONHUMAN SERVICES - ASSISTANCE PAYMENTHUMAN SERVICES - CCUSOHUMAN SERVICES - CHEROKEEHUMAN SERVICES - COMMUNITY SERVICESHUMAN SERVICES - ELDORA STATE TRAINING SCHOOLHUMAN SERVICES - GLENWOODHUMAN SERVICES - INDEPENDENCEHUMAN SERVICES - WOODWARDINSPECTIONS AND APPEALSINSURANCEIOWA COMMUNICATIONS NETWORKIOWA DEPARTMENT ON AGINGIOWA ECONOMIC DEVELOPMENT AUTHORITYIOWA LOTTERY AUTHORITYIOWA PUBLIC TVIOWA VETERANS HOMEIOWA WORKFORCE DEVELOPMENTIPERSJUDICIAL BRANCHLAW ENFORCEMENT ACADEMYLEGISLATIVE - HOUSELEGISLATIVE - JOINT EXPENSELEGISLATIVE - OFFICE OF OMBUDSMANLEGISLATIVE - SENATELEGISLATIVE - SERVICES AGENCYNATURAL RESOURCESOFFICE CHIEF INFORMATION OFFICERPAROLE BOARDPROFESSIONAL LICENSINGPUBLIC DEFENSEPUBLIC EMPLOYMENT RELATIONS BOARD (PERB)PUBLIC HEALTHPUBLIC INFORMATION OFFICEPUBLIC SAFETYRACING AND GAMING COMMISSIONREVENUESECRETARY OF STATESTATE PUBLIC DEFENDERTREASURER OF STATEUTILITIES BOARDVETERANS AFFAIRSVOCATIONAL REHABILITATION Reason for Request * Did not Receive Form / Lost Form Incorrect Information on Form** Other** **Please Describe in Detail: * NOTE: Your Form 1095 will be mailed from outside the state of Iowa via USPS. Please allow ample time for mail delivery. First Name * MI Last Name * Street/Mailing Address * City * State * Zip Code * Last 4 Digits of Policy Holder SSN * Email Address Daytime Phone Number * Please indicate how you would like to be contacted: * Mail 1095 Form to address above (via USPS) Email 1095 Form to email address above*** Call me at the phone number above Email response to question at email address above*** NOTE: ***If selecting Email as a contact method, you are granting the State of Iowa permission to email confidential information.
