1095-B CORRECTION SOURCE PACKET
Provider / year / statement group / responsible individual / covered-person keys:
Original source version / output version / furnished state / filed state / actual outcome:
Original references / case ID:
CHANGE EVIDENCE
Source owner / discovery date / event entry date / effective period / supporting record / approved reason:
BEFORE-AFTER
Person | original months | revised months | unchanged identity or fields | source evidence
FICTIONAL CR-32
Original adults 12 + 12, child 12 = 36 person-months.
Revised adults 12 + 12, child Jan-Apr 4 = 28.
Three covered people remain; child May-Dec changes eight cells.
Complete revised record / reviewer / source version approved:
HANDOFF
Preparation owner / original outcome and association references / filing-team review:
Agency follow-up outcome / corrected recipient copy owner and evidence:
New unresolved question / later source change / preserved history: