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

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Long Term Care and Accelerated Death Benefits Form 1099-LTC

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The Long Term Care and Accelerated Death Benefits Form 1099-LTC form is 6 pages long and contains:

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Form 1099-LTC
2019
Cat. No. 23021Z
Long-Term Care and
Accelerated Death
Benefits
Copy A
For
Internal Revenue
Service Center
Department of the Treasury - Internal Revenue Service
File with Form 1096.
OMB No. 1545-1519
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2019 General
Instructions for
Certain
Information
Returns.
9393
VOID CORRECTED
www.irs.gov/Form1099LTC
PAYER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.
PAYER’S TIN POLICYHOLDER'S TIN
POLICYHOLDER'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
1 Gross long-term care
benefits paid
$
2 Accelerated death benefits
paid
$
3 Check one:
Per
diem
Reimbursed
amount
INSURED'S TIN
INSURED'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
4 Qualified contract
(optional)
5 Check, if applicable:
(optional)
Chronically ill
Terminally ill
Date certified
Form 1099-LTC
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
Form 1099-LTC
2019
Long-Term Care and
Accelerated Death
Benefits
Copy B
For Policyholder
Department of the Treasury - Internal Revenue Service
This is important tax
information and is being
furnished to the IRS. 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.
OMB No. 1545-1519
CORRECTED (if checked)
PAYER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.
PAYER’S TIN POLICYHOLDER'S TIN
POLICYHOLDER'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
1 Gross long-term care
benefits paid
$
2 Accelerated death benefits
paid
$
3
Per
diem
Reimbursed
amount
INSURED'S TIN
INSURED'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
4 Qualified contract
(optional)
5 (optional)
Chronically ill
Terminally ill
Date certified
Form 1099-LTC
(keep for your records)
www.irs.gov/Form1099LTC
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 long-
term 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.
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.
Policyholder's taxpayer identification number (TIN). For your protection, this
form may show only the last four digits of your TIN (social security number
(SSN), individual taxpayer identification number (ITIN), adoption taxpayer
identification number (ATIN), or employer identification number (EIN)). However,
the issuer has reported your complete TIN to the IRS.
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.
Box 5. May show if the insured was certified chronically ill or terminally ill, and
the latest date certified.
Future developments. For the latest developments related to Form 1099-LTC
and its instructions, such as legislation enacted after they were published, go to
www.irs.gov/Form1099LTC.
Form 1099-LTC
2019
Long-Term Care and
Accelerated Death
Benefits
Copy C
For Insured
Department of the Treasury - Internal Revenue Service
Copy C is
provided to you
for information
only. Only the
policyholder is
required to
report this
information on
a tax return.
OMB No. 1545-1519
CORRECTED (if checked)
PAYER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.
PAYER’S TIN POLICYHOLDER'S TIN
POLICYHOLDER'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
1 Gross long-term care
benefits paid
$
2 Accelerated death benefits
paid
$
3
Per
diem
Reimbursed
amount
INSURED'S TIN
INSURED'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
4 Qualified contract
(optional)
5 (optional)
Chronically ill
Terminally ill
Date certified
Form 1099-LTC
(keep for your records)
www.irs.gov/Form1099LTC
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 taxpayer identification number (TIN). For your
protection, this form may show only the last four digits of
your TIN (social security number (SSN), individual taxpayer
identification number (ITIN), adoption taxpayer
identification number (ATIN), or employer identification
number (EIN)). However, the issuer has reported your
complete TIN to the IRS.
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.
Future developments. For the latest developments related
to Form 1099-LTC and its instructions, such as legislation
enacted after they were published, go to www.irs.gov/
Form1099LTC.
Form 1099-LTC
2019
Long-Term Care and
Accelerated Death
Benefits
Copy D
For Payer
Department of the Treasury - Internal Revenue Service
OMB No. 1545-1519
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2019 General
Instructions for
Certain
Information
Returns.
VOID CORRECTED
PAYER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.
PAYER’S TIN POLICYHOLDER'S TIN
POLICYHOLDER'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
1 Gross long-term care
benefits paid
$
2 Accelerated death benefits
paid
$
3
Per
diem
Reimbursed
amount
INSURED'S TIN
INSURED'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
4 Qualified contract
(optional)
5 Check, if applicable:
(optional)
Chronically ill
Terminally ill
Date certified
Form 1099-LTC
www.irs.gov/Form1099LTC
Instructions for Payer
To complete Form 1099-LTC, use:
• The 2019 General Instructions for Certain Information
Returns, and
• The 2019 Instructions for Form 1099-LTC.
To get or to order these instructions, go to
www.irs.gov/Form1099LTC.
Due dates. Furnish Copy B of this form to the
policyholder by January 31, 2020.
Furnish Copy C of this form to the insured by
January 31, 2020.
File Copy A of this form with the IRS by February 28,
2020. If you file electronically, the due date is March 31,
2020. To file electronically, you must have software that
generates a file according to the specifications in Pub.
1220.
Need help? If you have questions about reporting on
Form 1099-LTC, call the information reporting customer
service site toll free at 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).
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Long Term Care and Accelerated Death Benefits Form 1099-LTC

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Completed 21 May 2019

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