FORM 1095 WILL NOT BE MAILED AUTOMATICALLY

Employees and other covered individuals may request a copy of their Form 1095 at no cost.

Once requested, the form will be provided within 30 days of the request or by the applicable IRS deadline, whichever is later.

HOW TO REQUEST YOUR FORM 1095

You may request your Form 1095 using any of the methods below:

Mail:

Saelens LLC

Attn: Human Resources / Benefits

100 Veterans Drive

PO Box 499

Johnson Creek, WI 53038

Email:      [email protected]                or            [email protected]

Phone:     Melissa: 920-988-4455           or           Abby: 920-988-0165

This notice is provided in accordance with IRS requirements to ensure employees are informed of how to obtain their Form 1095.

If you have questions, please contact Human Resources using one of the methods listed above.