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

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Page 1 of 8 of Form 1099-LTC (Page 2 is BLANK)

3

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reproduction proofs. MUST be removed before printing.

Date

Signature

O.K. to print

Separation 1, Form 1099-LTC - Prints in Red Ink, J-6983.
Date

Revised proofs
requested

Separation 2, Form 1099-LTC - Prints in Black Ink.

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Deletions are marked in red.
Changes are highlighted in yellow

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9393

VOID

CORRECTED
OMB No. 1545-1519

1 Gross long-term care
benefits paid

PAYER’S name, street address, city, state, ZIP code, and telephone no.

2009

$
2 Accelerated death
benefits paid

$
PAYER’S federal identification number

POLICYHOLDER’S identification number

POLICYHOLDER’S name

Form

3 Check one:
Per
Reimbursed
diem
amount
INSURED’S name

Long-Term Care and
Accelerated Death
Benefits

1099-LTC

INSURED’S social security no.

Copy A
For
Internal Revenue
Service Center
File with Form 1096.

Street address (including apt. no.)

Street address (including apt. no.)

City, state, and ZIP code

City, state, and ZIP code

Account number (see instructions)

Form

1099-LTC

4 Qualified contract
(optional)

5 Check, if applicable:
(optional)

Cat. No. 23021Z

Do Not Cut or Separate Forms on This Page

Chronically ill
Terminally ill

Date certified

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2009 General
Instructions for
Forms 1099, 1098,
3921, 3922, 5498,
and W-2G.

Department of the Treasury - Internal Revenue Service

— Do Not Cut or Separate Forms on This Page

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Page 3 of 8 of Form 1099-LTC

3

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

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

1 Gross long-term care
benefits paid

OMB No. 1545-1519

$

2009

2 Accelerated death
benefits paid

$
PAYER’S federal identification number

POLICYHOLDER’S identification number

Form

3

POLICYHOLDER’S name

Street address (including apt. no.)

Street address (including apt. no.)

City, state, and ZIP code

City, state, and ZIP code

Form

1099-LTC

4 Qualified contract
(optional)

5 (optional)

(keep for your records)

1099-LTC

INSURED’S social security no.

Per
Reimbursed
diem
amount
INSURED’S name

Account number (see instructions)

Long-Term Care and
Accelerated Death
Benefits
Copy B
For Policyholder

Chronically ill

Date certified

Terminally ill

This is important tax
information and is being
furnished to the Internal
Revenue Service. 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.

Department of the Treasury - Internal Revenue Service

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Page 4 of 8 of Form 1099-LTC

3

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

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, Taxable and Nontaxable Income, and Form 8853,
Archer MSAs and Long-Term Care Insurance Contracts, 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.
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.

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Page 5 of 8 of Form 1099-LTC

3

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

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

1 Gross long-term care
benefits paid

OMB No. 1545-1519

2009

$
2 Accelerated death
benefits paid

$
PAYER’S federal identification number

POLICYHOLDER’S identification number

Form

3

INSURED’S social security no.

Copy C
For Insured

Street address (including apt. no.)

Street address (including apt. no.)

City, state, and ZIP code

City, state, and ZIP code

Account number (see instructions)

Form

1099-LTC

1099-LTC

Per
Reimbursed
diem
amount
INSURED’S name

POLICYHOLDER’S name

4 Qualified contract
(optional)

5 (optional)

(keep for your records)

Long-Term Care and
Accelerated Death
Benefits

Chronically ill

Date certified

Copy C is
provided to you
for information
only. Only the
policyholder is
required to
report this
information on
a tax return.

Terminally ill
Department of the Treasury - Internal Revenue Service

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Page 6 of 8 of Form 1099-LTC

3

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

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.
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.

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Page 7 of 8 of Form 1099-LTC

3

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

VOID

CORRECTED

PAYER’S name, street address, city, state, ZIP code, and telephone no.

1 Gross long-term care
benefits paid

OMB No. 1545-1519

2009

$
2 Accelerated death
benefits paid

$
PAYER’S federal identification number

POLICYHOLDER’S identification number

Form

3

INSURED’S social security no.

Street address (including apt. no.)

City, state, and ZIP code

City, state, and ZIP code

Account number (see instructions)

1099-LTC

4 Qualified contract
(optional)

5 Check, if applicable:
(optional)

Copy D
For Payer

Street address (including apt. no.)

Form

1099-LTC

Per
Reimbursed
diem
amount
INSURED’S name

POLICYHOLDER’S name

Long-Term Care and
Accelerated Death
Benefits

Chronically ill

Date certified

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2009 General
Instructions for
Forms 1099, 1098,
3921, 3922, 5498,
and W-2G.

Terminally ill
Department of the Treasury - Internal Revenue Service

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Page 8 of 8 of Form 1099-LTC

3

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

Instructions for Payers
General and specific form instructions are provided as
separate products. The products you should use to
complete Form 1099-LTC are the 2009 General
Instructions for Forms 1099, 1098, 3921, 3922, 5498,
and W-2G and the 2009 Instructions for Form
1099-LTC. 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 forms are scanned during
processing, you cannot file Form 1096, 1098, 1099,
3921, 3922, or 5498 that you print from the IRS
website.
Due dates. Furnish Copy B of this form to the
policyholder by February 1, 2010.

Furnish Copy C of this form to the insured by
February 1, 2010.
File Copy A of this form with the IRS by
March 1, 2010. If you file electronically, the due date is
March 31, 2010. To file electronically, you must have
software that generates a file according to the
specifications in Pub. 1220, Specifications for Filing
Forms 1098, 1099, 3921, 3922, 5498, and W-2G
Electronically. IRS does not provide a fill-in form
option.
Need help? If you have questions about reporting on
Form 1099-LTC, 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).

Printed on recycled paper

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