1099-H Health Coverage Tax Credit (HCTC) Advance Payments

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7171

VOID

CORRECTED

ISSUER'S/PROVIDER'S name, street address, city or town, state or province, 1 Amount of HCTC advance
payments
country, ZIP or foreign postal code, and telephone no.
$
2 No. of mos. HCTC
payments received

OMB No. 1545-1813

2016
Form 1099-H

ISSUER'S/PROVIDER'S federal identification number

RECIPIENT'S identification number

RECIPIENT'S name

Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code

3 Jan.

9 July

$

$

4 Feb.

10 Aug.

$

$

5 Mar.

11 Sept.

$

$

6 Apr.

12 Oct.

$

$

7 May

13 Nov.

$

$

8 June

14 Dec.

$

$

Health Coverage
Tax Credit (HCTC)
Advance Payments
Copy A
For
Internal Revenue
Service Center
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2016 General
Instructions for
Certain Information
Returns.

1099-H
Cat. No. 34912D
www.irs.gov/form1099h
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

CORRECTED (if checked)
ISSUER'S/PROVIDER'S name, street address, city or town, state or province, 1 Amount of HCTC advance
payments
country, ZIP or foreign postal code, and telephone no.
$
2 No. of mos. of HCTC advance
payments and reimbursement
credits paid to you

OMB No. 1545-1813

2016
Form 1099-H

ISSUER'S/PROVIDER'S federal identification number

RECIPIENT'S identification number

RECIPIENT'S name

Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code

Form

1099-H

(keep for your records)

3 Jan.

9 July

$

$

4 Feb.

10 Aug.

$

$

5 Mar.

11 Sept.

$

$

6 Apr.

12 Oct.

$

$

7 May

13 Nov.

$

$

8 June

14 Dec.

$

$

www.irs.gov/form1099h

Health Coverage
Tax Credit (HCTC)
Advance Payments

Copy B
For Recipient
This is important
tax information
and is being
furnished to the
Internal Revenue
Service.

Department of the Treasury - Internal Revenue Service

Instructions for Recipient
This statement is provided to you because you received
Health Coverage Tax Credit (HCTC) advance payments
of your health coverage insurance premiums. These
advance payments were forwarded directly to your
health insurance provider. You are qualified to receive
advance payments if you were an eligible trade
adjustment assistance (TAA), Alternative TAA,
Reemployment TAA recipient, or a Pension Benefit
Guaranty Corporation (PBGC) pension payee. See Form
8885, Health Coverage Tax Credit, and its instructions
for more details on qualified recipients and how to figure
any credit that you may be able to take on your Form
1040, 1040NR, 1040-SS, or 1040-PR.
Box 1. Shows the total amount of HCTC advance
payments of qualified health insurance costs that were
made on your behalf.

Box 2. Shows the total number of months you received
HCTC payments.
Boxes 3 through 14. Shows the amount of HCTC
advance payments paid for you for each month. The
total of the amounts shown in these boxes equals the
amount shown in box 1.

Future Developments
For the latest information about developments related to
Form 1099-H and its instructions, such as legislation
enacted after they were published, go to
www.irs.gov/form1099h.

VOID

CORRECTED

ISSUER'S/PROVIDER'S name, street address, city or town, state or province, 1 Amount of HCTC advance
payments
country, ZIP or foreign postal code, and telephone no.
$
2 No. of mos. HCTC
payments received

OMB No. 1545-1813

2016
Form 1099-H

ISSUER'S/PROVIDER'S federal identification number

RECIPIENT'S identification number

RECIPIENT'S name

Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code

Form

1099-H

3 Jan.

9 July

$

$

4 Feb.

10 Aug.

$

$

5 Mar.

11 Sept.

$

$

6 Apr.

12 Oct.

$

$

7 May

13 Nov.

$

$

8 June

14 Dec.

$

$

www.irs.gov/form1099h

Health Coverage
Tax Credit (HCTC)
Advance Payments

Copy C
For
Issuer/Provider
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2016 General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Issuer/Provider
To complete Form 1099-H, use:
• the 2016 General Instructions for Certain Information
Returns, and
• the 2016 Instructions for Form 1099-H.
To order these instructions and additional forms, go to
www.irs.gov/form1099h.
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 recipient
by January 31, 2017.

File Copy A of this form with the IRS by
February 28, 2017. If you file electronically, the due date
is March 31, 2017. To file electronically, you must have
software that generates a file according to the
specifications in Pub. 1220. The IRS does not provide a
fill-in form option.
Need help? If you have questions about reporting on
Form 1099-H, call the information reporting customer
service site toll free at 1-866-455-7438 or 304-263-8700
(not toll free). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).