Form 1099-H (2012) 1099-H (2012) Health Coverage Tax Credit (HCTC) Advance Payments

Attention:
This form is provided for informational purposes only. Copy A appears in red, similar to
the official IRS form. Do not file Copy A downloaded from this website. You can only file
printed versions of Copy A that comply with Publication 1179.
The HCTC Transaction Center, as an administrator of the Health Coverage Tax Credit
(HCTC), will file the required returns and furnish statements to the recipients unless you
elect to file and furnish information returns and statements on your own. Contact the
HCTC Transaction Center for this purpose by calling 1-866-628-4282.

7171

VOID

CORRECTED

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

1 Amount of HCTC advance
payments
$
2 No. of mos. HCTC
payments received

OMB No. 1545-1813

2012
Form 1099-H

ISSUER'S/PROVIDER'S federal identification number

RECIPIENT'S name

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

RECIPIENT'S identification number

3 Jan.

9 July

$

$

4 Feb.

10 Aug.

Health Coverage
Tax Credit (HCTC)
Advance Payments
Copy A
For
Internal Revenue
Service Center

$

$

5 Mar.

11 Sept.

File with Form 1096.

$

$

6 Apr.

12 Oct.

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2012 General
Instructions for
Certain Information
Returns.

$

$

7 May

13 Nov.

$

$

8 June

14 Dec.

$

$

1099-H
Cat. No. 34912D
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

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

1 Amount of HCTC advance
payments
$
2 No. of mos. HCTC
payments received

OMB No. 1545-1813

2012
Form 1099-H

ISSUER'S/PROVIDER'S federal identification number

RECIPIENT'S name

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

Form

1099-H

RECIPIENT'S identification number

3 Jan.

9 July

$

$

4 Feb.

10 Aug.

$

$

5 Mar.

11 Sept.

$

$

6 Apr.

12 Oct.

$

$

7 May

13 Nov.

$

$

8 June

14 Dec.

$

$

(keep for your records)

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 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.

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

1 Amt. of HCTC advance payments and
reimbursement credits paid to you

$
2 No. of mos. HCTC advance payments
and reimbursement credits received

OMB No. 1545-1813

2012
Form 1099-H

ISSUER'S/PROVIDER'S federal identification number

RECIPIENT'S name

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

Form

1099-H

RECIPIENT'S identification number

3 Jan.

9 July

$

$

4 Feb.

10 Aug.

$

$

5 Mar.

11 Sept.

$

$

6 Apr.

12 Oct.

$

$

7 May

13 Nov.

$

$

8 June

14 Dec.

$

$

(keep for your records)

Health Coverage
Tax Credit (HCTC)
Advance Payments

Copy 1
For Recipient
(Issued by the
HCTC Program)
This is important
tax information
and is being
furnished to the
Internal Revenue
Service.

Department of the Treasury - Internal Revenue Service

DO NOT FILE THIS FORM WITH YOUR FEDERAL INCOME TAX RETURN. THIS FORM IS FOR YOUR INFORMATION ONLY.

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 the HCTC Program made
monthly payment(s) to your health plan to cover a portion of your health
insurance costs in 2012. These payments are referred to on this
statement as advance payments. These advance payments are shown
in Boxes 1 through 14 as follows:
Box 1. Shows the total amount of HCTC advance payments that were
made on your behalf for the entire year, as well as the total amount of
reimbursement credits paid to you prior to your HCTC enrollment.
Box 2. Shows the total number of months HCTC advance payments or
reimbursement credits were made on your behalf.
Boxes 3 through 14. Shows the total amount of any HCTC advance
payments or reimbursement credits that were made on your behalf
each month. The sum of these amounts equals the amount shown in
Box 1.

Note. This statement reflects the tax credit that you and any qualified
family members received in 2012 through the monthly HCTC Program.
It does not reflect payments you made to the HCTC Program (“U.S.
Treasury – HCTC”) which were forwarded to your health plan by the
HCTC Program.
Any HCTC amount listed on this statement cannot be claimed on
your federal income tax return. Claiming this amount means you
would receive the credit twice. If you receive the credit for amounts you
are not entitled to, you will be required to repay the IRS. Only payments
you paid directly to your health plan can be claimed on your federal
income tax return. This means any amounts for which you received an
advance payment or reimbursement credit cannot be claimed on your
tax return (any reimbursement credits will be reflected on this form). For
example, if you paid $100 to your health plan and received a $72.50
advance payment or reimbursement credit, you cannot claim the same
$100 on your tax return. Similarly, if you sent $27.50 to the HCTC
Program to cover your portion of your monthly $100 health plan
premium, you cannot claim that payment on your tax return because
you already received the $72.50 tax credit. See IRS Form 8885 for more
information on these requirements.
Need help? If you have any questions regarding this statement, call the
HCTC Customer Contact Center toll-free at 1-866-628-HCTC (4282). If
you have a hearing impairment, call 1-866-626-4282 (TTY). For general
information about the HCTC, visit IRS.gov (keyword/Search: HCTC).

VOID

CORRECTED

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

1 Amount of HCTC advance
payments
$
2 No. of mos. HCTC
payments received

OMB No. 1545-1813

2012
Form 1099-H

ISSUER'S/PROVIDER'S federal identification number

RECIPIENT'S name

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

Form

1099-H

RECIPIENT'S identification number

3 Jan.

Health Coverage
Tax Credit (HCTC)
Advance Payments

9 July

$

$

4 Feb.

10 Aug.

$

$

5 Mar.

11 Sept.

$

$

6 Apr.

12 Oct.

$

$

7 May

13 Nov.

$

$

8 June

14 Dec.

$

$

Copy C
For
Issuer/Provider
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2012 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. These products are the 2012
General Instructions for Certain Information Returns and
the 2012 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 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,
1097, 1098, 1099, 3921, 3922, or 5498 that you print
from IRS.gov.
Due dates. Furnish Copy B of this form to the recipient
by January 31, 2013. Copy 1 is furnished by the HCTC
Transaction Center.
File Copy A of this form with the IRS by
February 28, 2013. If you file electronically, the due date
is April 1, 2013. To file electronically, you must have

software that generates a file according to the
specifications in Pub. 1220, Specifications for Filing
Forms 1097, 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.
Future developments. The IRS has created a page on
IRS.gov for information about Form 1099-H and its
instructions, at www.irs.gov/form1099h. Information
about any future developments affecting Form 1099-H
(such as legislation enacted after we release it) will be
posted on that page.