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:

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* 2. Last Name:

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* 3. Associate ID:

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* 4. Company:

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* 5. Site Location:

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* 6. SSN (last 4 digits only):

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* 7. Employment Status:

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* 8. Email Address:

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

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* 10. Telephone #:

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* 11. I am requesting my Form 1095-C be sent via:

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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.

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* 13. Electronic Signature

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* 14. Today's Date

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