Form 1099-LTC Long-Term Care and Accelerated Death Benefits

9393

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

VOID

CORRECTED

PAYER'S name, street address, city, state, ZIP code, and telephone no.

1 Gross long-term care
benefits paid

$
2 Accelerated death
benefits paid

OMB No. 1545-1519

2012

DRAFT AS OF
June 22, 2011
$

PAYER’S federal identification number

POLICYHOLDER'S identification number

POLICYHOLDER'S name

3 Check one:
Per
Reimbursed
diem
amount
INSURED'S name

Form 1099-LTC
INSURED'S social security no.

Street address (including apt. no.)

Street address (including apt. no.)

City, state, and ZIP code

City, state, and ZIP code

Account number (see instructions)

4 Qualified contract
(optional)

5 Check, if applicable:
(optional)

Long-Term Care and
Accelerated Death
Benefits

Chronically ill
Terminally ill

Date certified

Copy A

For
Internal Revenue
Service Center

File with Form 1096.

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2012 General
Instructions for
Certain
Information
Returns.

1099-LTC
Cat. No. 23021Z
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

Form

Ok to print as is □
✔

Ok to print as corrected □

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

CORRECTED (if checked)
PAYER'S name, street address, city, state, ZIP code, and telephone no.

1 Gross long-term care
benefits paid

$
2 Accelerated death
benefits paid

OMB No. 1545-1519

2012

DRAFT AS OF
June 22, 2011
$

PAYER’S federal identification number

POLICYHOLDER'S identification number

3

Form 1099-LTC
INSURED'S social security no.

POLICYHOLDER'S name

Per
Reimbursed
diem
amount
INSURED'S name

Street address (including apt. no.)

Street address (including apt. no.)

City, state, and ZIP code

City, state, and ZIP code

Account number (see instructions)
Form

1099-LTC

4 Qualified contract
(optional)

5 (optional)

(keep for your records)

Long-Term Care and
Accelerated Death
Benefits

Chronically ill
Terminally ill

Copy B
For Policyholder

Date certified

This is important tax
information and is being
furnished to the Internal
Revenue Service. If you
are required to file a
return, a negligence
penalty or other
sanction may be
imposed on you if this
item is required to be
reported and the IRS
determines that it has
not been reported.

Department of the Treasury - Internal Revenue Service

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

Instructions for Policyholder
A payer, such as an insurance company or a viatical settlement provider, must
give this form to you for payments made under a long-term care insurance
contract or for accelerated death benefits. Payments include those made
directly to you (or to the insured) and those made to third parties.
A long-term care insurance contract provides coverage of expenses for longterm care services for an individual who has been certified by a licensed health
care practitioner as chronically ill. A life insurance company or viatical settlement
provider may pay accelerated death benefits if the insured has been certified by
either a physician as terminally ill or by a licensed health care practitioner as
chronically ill.
Policyholder's identification number. For your protection, this form may show
only the last four digits of your social security number (SSN), individual taxpayer
identification number (ITIN), or adoption taxpayer identification number (ATIN).
However, the issuer has reported your complete identification number to the
IRS, and, where applicable, to state and/or local governments.
Long-term care insurance contract. Generally, amounts received under a
qualified long-term care insurance contract are excluded from your income.
However, if payments are made on a per diem basis, the amount you may
exclude is limited. The per diem exclusion limit must be allocated among all
policyholders who own qualified long-term care insurance contracts for the
same insured. See Pub. 525 and Form 8853, and its instructions for more
information.

Per diem basis. This means the payments were made on any periodic basis
without regard to the actual expenses incurred during the period to which the
payments relate.
Accelerated death benefits. Amounts paid as accelerated death benefits are
fully excludable from your income if the insured has been certified by a
physician as terminally ill. Accelerated death benefits paid on behalf of
individuals who are certified as chronically ill are excludable from income to the
same extent they would be if paid under a qualified long-term care insurance
contract.
Account number. May show an account or other unique number the payer
assigned to distinguish your account.
Box 1. Shows the gross benefits paid under a long-term care insurance contract
during the year.
Box 2. Shows the gross accelerated death benefits paid during the year.
Box 3. Shows if the amount in box 1 or 2 was paid on a per diem basis or was
reimbursement of actual long-term care expenses. If the insured was terminally
ill, this box may not be checked.
Box 4. May show if the benefits were from a qualified long-term care insurance
contract.

DRAFT AS OF
June 22, 2011

Box 5. May show if the insured was certified chronically ill or terminally ill, and
the latest date certified.

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

CORRECTED (if checked)
PAYER'S name, street address, city, state, ZIP code, and telephone no.

1 Gross long-term care
benefits paid

$
2 Accelerated death
benefits paid

OMB No. 1545-1519

2012

DRAFT AS OF
June 22, 2011
$

PAYER’S federal identification number

POLICYHOLDER'S identification number

POLICYHOLDER'S name

3

Per
Reimbursed
diem
amount
INSURED'S name

Form 1099-LTC
INSURED'S social security no.

Street address (including apt. no.)

Street address (including apt. no.)

City, state, and ZIP code

City, state, and ZIP code

Account number (see instructions)
Form

1099-LTC

4 Qualified contract
(optional)

5 (optional)

(keep for your records)

Long-Term Care and
Accelerated Death
Benefits

Chronically ill

Copy C
For Insured

Date certified

Copy C is
provided to you
for information
only. Only the
policyholder is
required to
report this
information on
a tax return.

Terminally ill
Department of the Treasury - Internal Revenue Service

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

Instructions for Insured
A payer, such as an insurance company or a viatical
settlement provider, must give this form to you and to
the policyholder for payments made under a long-term
care insurance contract or for accelerated death
benefits. Payments include both benefits you received
directly and expenses paid on your behalf to third
parties.
If you are the insured but are not the policyholder,
Copy C is provided to you for information only because
these payments are not taxable to you. If you are also
the policyholder, you should receive Copy B.
Insured's identification number. For your protection,
this form may show only the last four digits of your
social security number (SSN), individual taxpayer
identification number (ITIN), or adoption taxpayer
identification number (ATIN). However, the issuer has
reported your complete identification number to the IRS,

and, where applicable, to state and/or local
governments.
Account number. May show an account or other
unique number the payer assigned to distinguish your
account.
Box 1. Shows the gross benefits paid under a long-term
care insurance contract during the year.
Box 2. Shows the gross accelerated death benefits paid
during the year.
Box 3. Shows if the amount in box 1 or 2 was paid on a
per diem basis or was reimbursement of actual
long-term care expenses. If you are terminally ill, this
box may not be checked.
Box 4. May show if the benefits were from a qualified
long-term care insurance contract.
Box 5. May show if you were certified chronically ill or
terminally ill, and the latest date certified.

DRAFT AS OF
June 22, 2011

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

VOID

CORRECTED

PAYER'S name, street address, city, state, ZIP code, and telephone no.

1 Gross long-term care
benefits paid

$

OMB No. 1545-1519

2012

DRAFT AS OF
June 22, 2011
2 Accelerated death
benefits paid

$

PAYER’S federal identification number

POLICYHOLDER'S identification number

POLICYHOLDER'S name

3

Per
Reimbursed
diem
amount
INSURED'S name

Form 1099-LTC
INSURED'S social security no.

Street address (including apt. no.)

Street address (including apt. no.)

City, state, and ZIP code

City, state, and ZIP code

Account number (see instructions)
Form

1099-LTC

4 Qualified contract
(optional)

5 Check, if applicable:
(optional)

Long-Term Care and
Accelerated Death
Benefits

Chronically ill

Copy D
For Payer

Date certified

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2012 General
Instructions for
Certain
Information
Returns.

Terminally ill
Department of the Treasury - Internal Revenue Service

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

Instructions for Payer
General and specific form instructions are provided as
separate products. The products you should use to
complete Form 1099-LTC are the 2012 General
Instructions for Certain Information Returns and the
2012 Instructions for Form 1099-LTC. A chart in the
general instructions gives a quick guide to which form
must be filed to report a particular payment. To order
these instructions and additional forms, visit IRS.gov or
call 1-800-TAX-FORM (1-800-829-3676).
Caution: Because paper forms are scanned during
processing, you cannot file Forms 1096, 1097, 1098,
1099, 3921, 3922, or 5498 that you print from the IRS
website.
Due dates. Furnish Copy B of this form to the
policyholder by January 31, 2013.

Furnish Copy C of this form to the insured by January
31, 2013.
File Copy A of this form with the IRS by February 28,
2013. If you file electronically, the due date is April 1,
2013. To file electronically, you must have software that
generates a file according to the specifications in Pub.
1220, Specifications for Filing Forms 1097, 1098, 1099,
3921, 3922, 5498, 8935, and W-2G Electronically. IRS
does not provide a fill-in form option.
Need help? If you have questions about reporting on
Form 1099-LTC, call the information reporting customer
service site toll free at 1-866-455-7438 or 304-263-8700
(not toll free). For TTY/TDD equipment, call
304-579-4827 (not toll free). The hours of operation are
Monday through Friday from 8:30 a.m. to 4:30 p.m.,
Eastern time.

DRAFT AS OF
June 22, 2011