Form 8935 Airplane Payments Report

These should be OCR numbers
4444
7171

VOID

CORRECTED

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

1.1 Total
Amountreported
of HCTC advance
$ payments

OMB No. 1545-1813

2009

$

PAYER'S

Form 8935
2 No. of mos. HCTC advance

shade area

ISSUER’S/PROVIDER’S federal identification no.

payments received

RECIPIENT’S identification number

RECIPIENT’S name

Jan.

3

Year

Feb.

$
10
2b Aug.

$
5

Mar.

$$
11
3b Sept.

2a
$

$

6 Apr.
4a

Street address (including apt. no.)

12
4b

Oct.
$
13 Nov.
5b

$
7

5aMay

City, state, and ZIP code

$

1099-H
8935 (Rev. 2-2009)

$

$

Cat. No. 34912D

Do Not Cut or Separate Forms on This Page

NOTE: This page
is all red and white
EXCEPT for OCR
number 4444.

$
14
6b Dec.

8 June
6a

shade this area

8935
Amount

37750T

—

Airline
Payments
Health
Coverage
Tax
Credit
(HCTC)
Report
Advance Payments

Form 1099-H
9 July

$
4

3a

Form

(Rev. February
2009)

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

Insert:
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
separate
Instructions for
Form 8935 (Rev.
February 2009).

(Rev. February 2009)
CORRECTED (if checked)
ISSUER’S/PROVIDER’S name, street address, city, state, ZIP code, and
telephone no.

1 Total
Amountreported
of HCTC advance
1.
$ payments
$

PAYER'S

Form 8935

2009

2 No. of mos. HCTC advance
payments received

ISSUER’S/PROVIDER’S federal identification no.

RECIPIENT’S identification number

3

Year

Jan.

shade area

$
5

$
11 Sept.
2b

$
6
$
7

$

Street address (including apt. no.)

3a

City, state, and ZIP code

4a May

Apr.

$
8 June
5a
$

1099-H
8935
(Rev. 2-2009)

(keep for your records)

NOTE: This page
is all black and
white.

Advance Payments

Amount

$
10 Aug.
1b

2a Mar.

Airline
Payments
Health
Coverage
Tax Credit (HCTC)
Reports

Form 1099-H
9 July

$
4

1a Feb.

RECIPIENT’S name

Form

OMB No. 1545-1813

12
3b

Oct.
$
13 Nov.
4b

Copy B
For Recipient
This is important
tax information
and is being
furnished to the
Internal Revenue
Service.

$
14
5b Dec.
$
Department of the Treasury - Internal Revenue Service

Instructions for Recipient
The information on this Form 8935 is submitted to the
Internal Revenue Service by the commercial airline
passenger carrier to report payment(s) made to you
under the approval of an order of a Federal
bankruptcy court in a case filed after September 11,
2001, and before January 1, 2007, in respect of your
interest in a bankruptcy claim against the carrier, any
note of the carrier (or amount paid in lieu of a note
being issued), or any other fixed obligation of the
carrier to pay a lump sum amount.
You received the payment(s) shown on this form
because you are a current or former employee of a
commercial airline passenger carrier who was a
participant in a defined benefit plan maintained by the
carrier, which is a plan described in section 401(a) of
the Internal Revenue Code of 1986, which includes a
trust exempt from tax under section 501(a) of such

Code, and the plan was terminated or became subject
to the restrictions contained in paragraphs (2) and (3)
of section 402(b) of the Pension Protection Act of
2006.
The payment(s) you received, as reported on this
form, are eligible for rollover into a Roth IRA within
180 days of receipt of such amount, or before June
23, 2009, whichever is later.
Box 1. Shows the entire amount you received, as
reported on this form, which is eligible for rollover
treatment.
Boxes 2a–6a. Shows each year in which you
received payments.
Boxes 2b–6b. Shows the amount you received each
year.

VOID

(Rev. February
2009)

CORRECTED

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

1 Total
Amountreported
of HCTC advance
1.
$ payments
$

2009

2 No. of mos. HCTC advance
payments received

PAYER'S
ISSUER’S/PROVIDER’S federal identification no.

RECIPIENT’S identification number

3

Jan.

$
4

RECIPIENT’S name

1a Feb.
shade area

$
5

2a

Mar.

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

6 Apr.
3a
$
7

4a May
$
8

5a
$
Form

OMB No. 1545-1813

Form 8935

1099-H(Rev. 2-2009)
8935

NOTE: This page
is all black and
white.

June

Year

Health
Coverage
Airline
Payments
Tax
Credit
(HCTC)
Report
Advance Payments

Form 1099-H
9 July

Amount

$
10
1b Aug.
$
11 Sept.

2b

$
12 Oct.
$
13 Nov.

3b

4b

$
14 Dec.

5b

Copy C
For Payer
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

Insert:
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
separate
Instructions for
Form 8935 (Rev.
February 2009).

Instructions for Payers
What’s New. This form is used to provide
information to recipients regarding payments you
made to current and former employees with respect to
certain claims made in certain bankruptcy
proceedings.
Specific form instructions are provided as a separate
product. You should use the Instructions for Form
8935 (Rev. February 2009), to complete this form. 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).
Due dates. Furnish Copy B of this form to the
recipient within 90 days of payment, or, if later, by
March 23, 2009.

File Copy A of this form electronically
through the FIRE system within 90 days of payment,
or, if later, by March 23, 2009. To file electronically,
you must have software that generates a file
according to the specifications in Announcement
2009-7, I.R.B. 2009-10, Update and Correction to
Pub. 1220, Specifications for Filing Forms 1098,
1099, 3921, 3922, 5498, and W-2G Electronically
containing formatting information for Form 8935,
Airline Payments Report. IRS does not provide a fillin form option.
Need help? If you have questions about reporting on
Form 8935, call the information reporting customer
service site toll free at 1-866-455-7438 or 304-2638700 (not toll free). For TTY/TDD equipment, call 302267-3367 (not toll free).