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9393 VOID CORRECTED
PAYER’S name, street address, city, state, ZIP code, and telephone no. 1 Gross long-term care OMB No. 1545-1519
benefits paid
$
2 Accelerated death
benefits paid
2008 Long-Term Care and
Accelerated Death
Benefits
$ Form 1099-LTC
PAYER’S federal identification number POLICYHOLDER’S identification number 3 Check one: INSURED’S social security no. Copy A
Per Reimbursed
diem amount For
POLICYHOLDER’S name INSURED’S name Internal Revenue
Service Center
File with Form 1096.
Street address (including apt. no.) Street address (including apt. no.) For Privacy Act
and Paperwork
Reduction Act
City, state, and ZIP code City, state, and ZIP code Notice, see the
2008 General
Instructions for
Account number (see instructions) 4 Qualified contract 5 Check, if applicable: Chronically ill Date certified Forms 1099, 1098,
(optional) (optional)
Terminally ill 5498, and W-2G.
Form 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
CORRECTED (if checked)
PAYER’S name, street address, city, state, ZIP code, and telephone no. 1 Gross long-term care OMB No. 1545-1519
benefits paid
$
2 Accelerated death
benefits paid
2008 Long-Term Care and
Accelerated Death
Benefits
$ Form 1099-LTC
PAYER’S federal identification number POLICYHOLDER’S identification number 3 INSURED’S social security no. Copy B
Per Reimbursed
diem amount For Policyholder
POLICYHOLDER’S name INSURED’S name This is important tax
information and is being
furnished to the Internal
Revenue Service. If you
are required to file a
Street address (including apt. no.) Street address (including apt. no.)
return, a negligence
penalty or other
sanction may be
City, state, and ZIP code City, state, and ZIP code
imposed on you if this
item is required to be
reported and the IRS
Account number (see instructions) 4 Qualified contract 5 (optional) Chronically ill Date certified
determines that it has
(optional)
Terminally ill not been reported.
Form 1099-LTC (keep for your records) Department of the Treasury - Internal Revenue Service
Instructions for Policyholder
A payer, such as an insurance company or a viatical settlement incurred during the period to which the payments relate.
provider, must give this form to you for payments made under a Accelerated death benefits. Amounts paid as accelerated
long-term care insurance contract or for accelerated death death benefits are fully excludable from your income if the
benefits. Payments include those made directly to you (or to the insured has been certified by a physician as terminally ill.
insured) and those made to third parties. Accelerated death benefits paid on behalf of individuals who are
A long-term care insurance contract provides coverage of certified as chronically ill are excludable from income to the
expenses for long-term care services for an individual who has same extent they would be if paid under a qualified long-term
been certified by a licensed health care practitioner as care insurance contract.
chronically ill. A life insurance company or viatical settlement
Account number. May show an account or other unique
provider may pay accelerated death benefits if the insured has
number the payer assigned to distinguish your account.
been certified by either a physician as terminally ill or by a
licensed health care practitioner as chronically ill. Box 1. Shows the gross benefits paid under a long-term care
insurance contract during the year.
Long-term care insurance contract. Generally, amounts
received under a qualified long-term care insurance contract are Box 2. Shows the gross accelerated death benefits paid during
excluded from your income. However, if payments are made on the year.
a per diem basis, the amount you may exclude is limited. The Box 3. Shows if the amount in box 1 or 2 was paid on a per
per diem exclusion limit must be allocated among all diem basis or was reimbursement of actual long-term care
policyholders who own qualified long-term care insurance expenses. If the insured was terminally ill, this box may not be
contracts for the same insured. See Pub. 525, Taxable and checked.
Nontaxable Income, and Form 8853, Archer MSAs and Box 4. May show if the benefits were from a qualified long-term
Long-Term Care Insurance Contracts, for more information. care insurance contract.
Per diem basis. This means the payments were made on a Box 5. May show if the insured was certified chronically ill or
periodic basis without regard to the actual expenses terminally ill, and the latest date certified.
CORRECTED (if checked)
PAYER’S name, street address, city, state, ZIP code, and telephone no. 1 Gross long-term care OMB No. 1545-1519
benefits paid
$
2 Accelerated death
benefits paid
2008 Long-Term Care and
Accelerated Death
Benefits
$ Form 1099-LTC
PAYER’S federal identification number POLICYHOLDER’S identification number 3 INSURED’S social security no.
Per Reimbursed
diem amount Copy C
POLICYHOLDER’S name INSURED’S name For Insured
Copy C is
provided to you
for information
Street address (including apt. no.) Street address (including apt. no.)
only. Only the
policyholder is
City, state, and ZIP code City, state, and ZIP code required to
report this
information on
Account number (see instructions) 4 Qualified contract 5 (optional) Chronically ill Date certified a tax return.
(optional)
Terminally ill
Form 1099-LTC (keep for your records) Department of the Treasury - Internal Revenue Service
Instructions for Insured
A payer, such as an insurance company or a viatical Box 1. Shows the gross benefits paid under a
settlement provider, must give this form to you and to long-term care insurance contract during the year.
the policyholder for payments made under a long-term Box 2. Shows the gross accelerated death benefits
care insurance contract or for accelerated death paid during the year.
benefits. Payments include both benefits you received
directly and expenses paid on your behalf to third Box 3. Shows if the amount in box 1 or 2 was paid on
parties. a per diem basis or was reimbursement of actual
long-term care expenses. If you are terminally ill, this
If you are the insured but are not the policyholder, box may not be checked.
Copy C is provided to you for information only Box 4. May show if the benefits were from a qualified
because these payments are not taxable to you. If you long-term care insurance contract.
are also the policyholder, you should receive Copy B.
Box 5. May show if you were certified chronically ill or
Account number. May show an account or other terminally ill, and the latest date certified.
unique number the payer assigned to distinguish your
account.
VOID CORRECTED
PAYER’S name, street address, city, state, ZIP code, and telephone no. 1 Gross long-term care OMB No. 1545-1519
benefits paid
$
2 Accelerated death
benefits paid
2008 Long-Term Care and
Accelerated Death
Benefits
$ Form 1099-LTC
PAYER’S federal identification number POLICYHOLDER’S identification number 3 INSURED’S social security no. Copy D
Per Reimbursed
diem amount For Payer
POLICYHOLDER’S name INSURED’S name
For Privacy Act
and Paperwork
Street address (including apt. no.) Street address (including apt. no.) Reduction Act
Notice, see the
2008 General
City, state, and ZIP code City, state, and ZIP code Instructions for
Forms 1099, 1098,
Account number (see instructions) 4 Qualified contract 5 Check, if applicable: Date certified
5498, and W-2G.
Chronically ill
(optional) (optional)
Terminally ill
Form 1099-LTC Department of the Treasury - Internal Revenue Service
Instructions for Payers
General and specific form instructions are provided as File Copy A of this form with the IRS by
separate products. The products you should use to March 2, 2009. If you file electronically, the due date is
complete Form 1099-LTC are the 2008 General March 31, 2009. To file electronically, you must have
Instructions for Forms 1099, 1098, 5498, and W-2G software that generates a file according to the
and the 2008 Instructions for Form 1099-LTC. A chart specifications in Pub. 1220, Specifications for Filing
in the general instructions gives a quick guide to which Forms 1098, 1099, 5498, and W-2G Electronically. IRS
form must be filed to report a particular payment. To does not provide a fill-in form option.
order these instructions and additional forms, visit the Need help? If you have questions about reporting on
IRS website at www.irs.gov or call 1-800-TAX-FORM Form 1099-LTC, call the information reporting
(1-800-829-3676). customer service site toll free at 1-866-455-7438 or
Caution: Because paper for ms are scanned dur ing 304-263-8700 (not toll free). For TTY/TDD equipment,
processing, you cannot file For m 1096, 1098, 1099, or call 304-267-3367 (not toll free). The hours of operation
5498 that you download and pr int from the IRS are Monday through Friday from 8:30 a.m. to 4:30
website. p.m., Eastern time.
Due dates. Furnish Copy B of this form to the
policyholder by February 2, 2009.
Furnish Copy C of this form to the insured by
February 2, 2009.
Printed on recycled paper