Plastipak Packaging/Absopure Water Co. et. Al. Health Plan

Form 1095-C is not required to file your annual income taxes. To request a copy of your Form 1095-C, you can complete the below online form, email benefitsdepartment@plastipak.com, call (734) 354-7294, or submit a written request to: Plastipak Packaging, Attn: Corporate Benefits, 41605 Ann Arbor Rd., Plymouth, MI 48170. Upon request, the Form will be provided timely, as required by the IRS.

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1. First Name: (Required.)

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2. Last Name: (Required.)

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3. Associate ID:

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4. Company: (Required.)

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5. Site Location: (Required.)

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6. SSN (last 4 digits only): (Required.)

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7. Employment Status: (Required.)

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8. Email Address: (Required.)

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9. Home Address (Street, City, State, Zip): (Required.)

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10. Telephone #: (Required.)

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11. I am requesting my Form 1095-C be sent via: (Required.)

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12. I acknowledge the above information is accurate and that Plastipak Packaging has my consent to provide the Form 1095-C per my request via the email or home address entered. (Required.)

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13. Electronic Signature (Required.)

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14. Today's Date (Required.)

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