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

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7171

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

2010

$
2 No. of mos. for which
HCTC payments received

ISSUER’S/PROVIDER’S federal identification no.

RECIPIENT’S identification number

RECIPIENT’S name

3

9

$
4

Feb.

$
10 Aug.

$
5

Mar.

$
11 Sept.

$
6
$
7

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

$
8

May

$
12 Oct.
$
13 Nov.

June

$
14 Dec.

Apr.

$
Form

1099-H

—

Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2010 General
Instructions for
Certain Information
Returns.

$

Cat. No. 34912D

Do Not Cut or Separate Forms on This Page

Form 1099-H
July

Jan.

Health Coverage
Tax Credit (HCTC)
Advance Payments

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

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

2010

$
2 No. of mos. for which
HCTC 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

Instructions for Recipient
Recipient’s identification number. For your protection,
this form may show only the last four digits of your social
security number (SSN), individual taxpayer identification
number (ITIN), or adoption taxpayer identification number
(ATIN). However, the issuer has reported your complete
identification number to the IRS and, where applicable, to
state and/or local governments.
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), Reemployment
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, 1040NR, 1040-SS, or
1040-PR.

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, 1040NR, 1040-SS, or 1040-PR,
because it was paid for you in advance.
Box 2. Shows the total number of months for which 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.

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

2010

$
2 No. of mos. for which
HCTC 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
2010 General
Instructions for
Certain Information
Returns.

$
Department of the Treasury - Internal Revenue Service

Instructions for Issuer/Provider
General and specific form instructions are
provided as separate products. The products you
should use for 2010 are the General Instructions
for Certain Information Returns and the 2010
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 forms are scanned
during processing, you cannot file with the IRS
Forms 1096, 1098, 1099, 3921, 3922, or 5498 that
you print from the IRS website.
Due dates. Furnish Copy B of this form to the
recipient by January 31, 2011.

File Copy A of this form with the IRS by
February 28, 2011. If you file electronically, the
due date is March 31, 2011. 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, 8935, and W-2G Electronically. 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 304-579-4827 (not toll free). The
hours of operation are Monday through Friday
from 8:30 a.m. to 4:30 p.m., Eastern time.