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

Attention:
Do not download, print, and file Copy A with the IRS.
Copy A appears in red, similar to the official IRS form,
but is for informational purposes only. A penalty of $50 per
information return may be imposed for filing copies of forms
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See IRS Publications 1141, 1167, 1179, and other IRS
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Date

Page 1 of 6 of Form 1099-H (Page 2 is BLANK.)

2

Action

The type and rule above prints on all proofs including departmental
reproduction proofs. MUST be removed before printing.

VOID

Revised proofs
requested

CORRECTED

ISSUER’S/PROVIDER’S name, street address, city, state, ZIP code, and
telephone no.

1 Amount of HCTC advance
payments

OMB No. 1545-1813

2007

$
2 No. of mos. HCTC advance
payments received

ISSUER’S/PROVIDER’S federal identification no.

RECIPIENT’S identification number

RECIPIENT’S name

City, state, and ZIP code

9

$
4

Feb.

$
10 Aug.

$
5

Mar.

$
11 Sept.

$
8

May

$
12 Oct.
$
13 Nov.

June

$
14 Dec.

Apr.

$

1099-H

$

Cat. No. 34912D

Do Not Cut or Separate Forms on This Page

Form 1099-H
July

Jan.

3

$
6
$
7

Street address (including apt. no.)

Form

Signature

O.K. to print
Responsible
scan organization

Separation 1 for page 1 of Form 1099-H. Prints in
Red (J-6983) Ink.
Separation 2 for page 1 of Form 1099-H. Prints in Black Ink.

7171

Date

O.K. to print
T:FP:F

—

Health Coverage
Tax Credit (HCTC)
Advance Payments
Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2007 General
Instructions for
Forms 1099, 1098,
5498, and W-2G.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

Page 3 of 6 of Form 1099-H

2

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

CORRECTED (if checked)
ISSUER’S/PROVIDER’S name, street address, city, state, ZIP code, and
telephone no.

1 Amount of HCTC advance
payments

OMB No. 1545-1813

2007

$
2 No. of mos. HCTC advance
payments received

ISSUER’S/PROVIDER’S federal identification no.

RECIPIENT’S name

RECIPIENT’S identification number

Street address (including apt. no.)
City, state, and ZIP code

Jan.

9

$
4

Feb.

$
10 Aug.

Mar.

$
11 Sept.

$
6
$
7
$
8
$

Form

1099-H

Form 1099-H
July

3

$
5

(keep for your records)

May

$
12 Oct.
$
13 Nov.

June

$
14 Dec.

Apr.

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

Page 4 of 6 of Form 1099-H

2

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Instructions for Recipient
This statement is provided to you because you
received HCTC advance payments of your health
coverage insurance premiums. These advance
payments were forwarded directly to your health
insurance provider. You qualify to receive
advance payments if you were an eligible trade
adjustment assistance (TAA), alternative TAA, or a
Pension Benefit Guaranty Corporation (PBGC)
pension recipient. 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 or 1040NR.

Box 1. Shows the total amount of HCTC advance
payments of qualified health insurance costs that
were made on your behalf. Do not report this
amount on Form 8885. This amount is in lieu of
any credit you will be able to take on Form 1040
or 1040NR because it was paid for you in
advance.
Box 2. Shows the total number of months you
received HCTC advance 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.

Page 5 of 6 of Form 1099-H

2

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

VOID

CORRECTED

ISSUER’S/PROVIDER’S name, street address, city, state, ZIP code, and
telephone no.

1 Amount of HCTC advance
payments

OMB No. 1545-1813

2007

$
2 No. of mos. HCTC advance
payments received

ISSUER’S/PROVIDER’S federal identification no.

RECIPIENT’S name

RECIPIENT’S identification number

Street address (including apt. no.)
City, state, and ZIP code

Jan.

9

$
4

Feb.

$
10 Aug.

$
6
$
7
$
8
$

Form

1099-H

Form 1099-H
July

3

$
5

Mar.

$
11 Sept.

May

$
12 Oct.
$
13 Nov.

June

$
14 Dec.

Apr.

Health Coverage
Tax Credit (HCTC)
Advance Payments

Copy C
For Payer
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2007 General
Instructions for
Forms 1099, 1098,
5498, and W-2G.

$
Department of the Treasury - Internal Revenue Service

Page 6 of 6 of Form 1099-H

2

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Instructions for Issuer/Provider
General and specific form instructions are
provided as separate products. The products you
should use for 2007 are the General Instructions
for Forms 1099, 1098, 5498, and W-2G and the
2007 Instructions for Form 1099-H. 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 the IRS website at www.irs.gov or call
1-800-TAX-FORM (1-800-829-3676).
Caution: Because paper for ms are scanned
dur ing processing, you cannot file with the IRS
For ms 1096, 1098, 1099, or 5498 that you
download from the IRS website.
Due dates. Furnish Copy B of this form to the
recipient by January 31, 2008.

File Copy A of this form with the IRS by
February 28, 2008. If you file electronically, the
due date is March 31, 2008. To file electronically,
you must have software that generates a file
according to the specifications in Pub. 1220,
Specifications for Filing Forms 1098, 1099, 5498,
and W-2G Electronically or Magnetically. 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). For TTY/TDD
equipment, call 304-267-3367 (not toll free). The
hours of operation are Monday through Friday
from 8:30 a.m. to 4:30 p.m., Eastern time. The
service site can also be reached by email at
[email protected].