Form 1099-H
2019
Cat. No. 34912D
Health Coverage
Tax Credit (HCTC)
Advance Payments
Copy A
For
Internal Revenue
Service Center
Department of the Treasury - Internal Revenue Service
OMB No. 1545-1813
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2019 General
Instructions for
Certain Information
Returns.
7171
VOID CORRECTED
ISSUER'S/PROVIDER'S name, street address, city or town, state or
province, country, ZIP or foreign postal code, and telephone no.
ISSUER'S/PROVIDER'S TIN RECIPIENT'S TIN
RECIPIENT'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
1 Amount of HCTC advance
payments
$
2 No. of mos. HCTC
payments received
3 Jan.
$
4 Feb.
$
5 Mar.
$
6 Apr.
$
7 May
$
8 June
$
9 July
$
10 Aug.
$
11 Sept.
$
12 Oct.
$
13 Nov.
$
14 Dec.
$
Form
1099-H
www.irs.gov/Form1099H
Do Not Cut or Separate Forms on This Page Do Not Cut or Separate Forms on This Page
Form 1099-H
2019
Health Coverage
Tax Credit (HCTC)
Advance Payments
Copy B
For Recipient
Department of the Treasury - Internal Revenue Service
This is important
tax information
and is being
furnished to the
IRS.
OMB No. 1545-1813
CORRECTED (if checked)
ISSUER'S/PROVIDER'S name, street address, city or town, state or
province, country, ZIP or foreign postal code, and telephone no.
ISSUER'S/PROVIDER'S TIN RECIPIENT'S TIN
RECIPIENT'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
1 Amount of HCTC advance
payments
$
2
No. of mos. of HCTC advance
payments and reimbursement
credits paid to you
3 Jan.
$
4 Feb.
$
5 Mar.
$
6 Apr.
$
7 May
$
8 June
$
9 July
$
10 Aug.
$
11 Sept.
$
12 Oct.
$
13 Nov.
$
14 Dec.
$
Form
1099-H
(keep for your records)
www.irs.gov/Form1099H
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) recipient, an Alternative
TAA (ATAA) recipient, a Reemployment TAA (RTAA)
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.
Recipient’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), or
adoption taxpayer identification number (ATIN)).
However, the issuer has reported your complete TIN to
the IRS.
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.
Form 1099-H
2019
Health Coverage
Tax Credit (HCTC)
Advance Payments
Copy C
For
Issuer/Provider
Department of the Treasury - Internal Revenue Service
OMB No. 1545-1813
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2019 General
Instructions for
Certain Information
Returns.
VOID CORRECTED
ISSUER'S/PROVIDER'S name, street address, city or town, state or
province, country, ZIP or foreign postal code, and telephone no.
ISSUER'S/PROVIDER'S TIN RECIPIENT'S TIN
RECIPIENT'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
1 Amount of HCTC advance
payments
$
2 No. of mos. HCTC
payments received
3 Jan.
$
4 Feb.
$
5 Mar.
$
6 Apr.
$
7 May
$
8 June
$
9 July
$
10 Aug.
$
11 Sept.
$
12 Oct.
$
13 Nov.
$
14 Dec.
$
Form
1099-H
www.irs.gov/Form1099H
Instructions for Issuer/Provider
To complete Form 1099-H, use:
• The 2019 General Instructions for Certain Information
Returns, and
• The 2019 Instructions for Form 1099-H.
To order these instructions and additional forms, go to
www.irs.gov/Form1099H.
Due dates. Furnish Copy B of this form to the recipient
by January 31, 2020.
File Copy A of this form with the IRS electronically by
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-H, 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).
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome