1095-C Reissue Request Form



Please use this form to request only 1095-C tax forms.

Please complete this form, print and sign it, then fax it to Employee services at 303-860-4299. Or, mail it directly to Employee Services:

Employee Services
1800 Grant St.
Suite 400
400 UCA
Denver, CO 80203

We will mail a replacement 1095-C no later than four business days from receipt of this completed form.

Last updated: 2017

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