EMPLOYER FORM-FAMILY DECISION
Reporting year:
Legal employer / EIN reference:
ALE determination and group review:
Plan funding arrangement / effective dates:
Population reviewed:
Expected form family and transmittal:
Carrier coverage-reporting confirmation:
Nonemployee or special-arrangement questions:
Preparation owner:
Responsible filer:
Filing channel / acknowledgment owner:
Furnishing owner:
Reviewer / date: