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

9393

VOID

CORRECTED

PAYER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

1 Gross long-term care
benefits paid

$
2 Accelerated death benefits
paid
PAYER’S federal identification number

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

POLICYHOLDER'S identification number

$

OMB No. 1545-1519

2015

Long-Term Care and
Accelerated Death
Benefits

Form 1099-LTC

POLICYHOLDER'S name

For
Internal Revenue
Service Center

File with Form 1096.

Street address (including apt. no.)

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

4 Qualified contract
(optional)

5 Check, if applicable:
(optional)

Copy A

INSURED'S taxpayer identification no.

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

Chronically ill

Date certified

Terminally ill

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2015 General
Instructions for
Certain
Information
Returns.

1099-LTC
Cat. No. 23021Z
www.irs.gov/form1099ltc
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

Form

Internal Use Only
DRAFT AS OF
April 24, 2014

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

CORRECTED (if checked)
PAYER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

1 Gross long-term care
benefits paid

2015

$
2 Accelerated death benefits
paid
PAYER’S federal identification number

POLICYHOLDER'S identification number

$
Per
Reimbursed
diem
amount
INSURED'S name

Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form

1099-LTC

4 Qualified contract
(optional)

(keep for your records)

Long-Term Care and
Accelerated Death
Benefits

Form 1099-LTC
INSURED'S taxpayer identification no.

3
POLICYHOLDER'S name

OMB No. 1545-1519

Copy B
For Policyholder

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.)
return, a negligence
penalty or other
sanction may be
City or town, state or province, country, and ZIP or foreign postal code
imposed on you if this
item is required to be
reported and the IRS
5 (optional)
Date certified
Chronically ill
determines that it has
Terminally ill
not been reported.
www.irs.gov/form1099ltc

Department of the Treasury - Internal Revenue Service

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

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 longterm 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 and Form 8853, 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.
Policyholder'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.
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.
Future developments. For the latest developments related to Form 1099-LTC
and its instructions, such as legislation enacted after they were published, go to
www.irs.gov/form1099ltc.

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

CORRECTED (if checked)
PAYER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

1 Gross long-term care
benefits paid

2015

$
2 Accelerated death benefits
paid
PAYER’S federal identification number

POLICYHOLDER'S identification number

OMB No. 1545-1519

$

Long-Term Care and
Accelerated Death
Benefits

Form 1099-LTC
INSURED'S taxpayer identification no.

Per
Reimbursed
diem
amount
INSURED'S name

POLICYHOLDER'S name

Street address (including apt. no.)

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)
Form

1099-LTC

4 Qualified contract
(optional)

(keep for your records)

5 (optional)

Copy C
For Insured

3

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
www.irs.gov/form1099ltc

Department of the Treasury - Internal Revenue Service

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

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.
Insured'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.
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 longterm care insurance contract.
Box 5. May show if you were certified chronically ill or
terminally ill, and the latest date certified.
Future developments. For the latest developments related
to Form 1099-LTC and its instructions, such as legislation
enacted after they were published, go to www.irs.gov/
form1099ltc.

VOID

CORRECTED

PAYER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

1 Gross long-term care
benefits paid

$
2 Accelerated death benefits
paid
PAYER’S federal identification number

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

POLICYHOLDER'S identification number

$

OMB No. 1545-1519

2015

Long-Term Care and
Accelerated Death
Benefits

Form 1099-LTC
INSURED'S taxpayer identification no.

3

Per
Reimbursed
diem
amount
INSURED'S name

POLICYHOLDER'S name

Street address (including apt. no.)

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)
Form

1099-LTC

4 Qualified contract
(optional)

5 Check, if applicable:
(optional)

www.irs.gov/form1099ltc

Copy D
For Payer

Chronically ill

Date certified

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2015 General
Instructions for
Certain
Information
Returns.

Terminally ill
Department of the Treasury - Internal Revenue Service

Version A, Cycle 2
Dimensions: 7.3" x 3.5"

Instructions for Payer
To complete Form 1099-LTC, use:
• the 2015 General Instructions for Certain Information
Returns, and
• the 2015 Instructions for Form 1099-LTC.
To order these instructions and additional forms, go
to www.irs.gov/form1099ltc or call 1-800-TAX-FORM
(1-800-829-3676).
Caution. Because paper forms are scanned during
processing, you cannot file Forms 1096, 1097, 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, 2016.

Furnish Copy C of this form to the insured by
February 1, 2016.
File Copy A of this form with the IRS by February 29,
2016. If you file electronically, the due date is March 31,
2016. To file electronically, you must have software that
generates a file according to the specifications in Pub.
1220, Specifications for Electronic Filing of Forms 1097,
1098, 1099, 3921, 3922, 5498, 8935, and W-2G. The
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). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).