CORE|DAS ACA Team Contact | Iowa Department of Administrative Services

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.

	All 1095 Forms will be mailed by the required date of January 31, 2023, unless that date is extended by the IRS.
	Before requesting a duplicate, please allow ample time for mail delivery as the Forms are mailed outside of Iowa.

*Response required

What was your Status during the Reporting Year? *

Active State Employee

Retired/COBRA Covered Former Employee

Department/Agency *

Reason for Request *

Did not Receive Form / Lost Form

Incorrect Information on Form**

Other**

**Please Describe in Detail: *

NOTE: Your Form 1095 is mailed from outside the state of Iowa via USPS. Please allow ample time for mail delivery.

First Name *

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.

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