1099-H (2013) 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 or town, province or state, 1 Amount of HCTC advance
payments
country, ZIP or foreign postal code, and telephone no.
$
2 No. of mos. HCTC
payments received

OMB No. 1545-1813

2013
Form 1099-H

ISSUER'S/PROVIDER'S federal identification number

RECIPIENT'S identification number

RECIPIENT'S name

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

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
2013 General
Instructions for
Certain Information
Returns.

$

$

7 May

13 Nov.

$

$

8 June

14 Dec.

$

$

1099-H
Cat. No. 34912D
www.irs.gov/form1099h
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 or town, province or state, 1 Amount of HCTC advance
payments
country, ZIP or foreign postal code, and telephone no.
$
2 No. of mos. of HCTC advance
payments and reimbursement
credits paid to you

OMB No. 1545-1813

2013
Form 1099-H

ISSUER'S/PROVIDER'S federal identification number

RECIPIENT'S identification number

RECIPIENT'S name

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

Form

1099-H

(keep for your records)

3 Jan.

9 July

$

$

4 Feb.

10 Aug.

$

$

5 Mar.

11 Sept.

$

$

6 Apr.

12 Oct.

$

$

7 May

13 Nov.

$

$

8 June

14 Dec.

$

$

www.irs.gov/form1099h

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
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.

Future Developments
For the latest information about developments related to
Form 1099-H and its instructions, such as legislation
enacted after they were published, go to
www.irs.gov/form1099h.

CORRECTED (if checked)
ISSUER'S/PROVIDER'S name, street address, city or town, province or state, 1 Amt. of HCTC advance payments and
reimbursement credits paid to you
country, ZIP or foreign postal code, and telephone no.
$
2 No. of mos. HCTC advance payments

and reimbursement credits paid to you

OMB No. 1545-1813

2013
Form 1099-H

ISSUER'S/PROVIDER'S federal identification number

RECIPIENT'S identification number

RECIPIENT'S name

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

Form

1099-H

(keep for your records)

3 Jan.

9 July

$

$

4 Feb.

10 Aug.

$

$

5 Mar.

11 Sept.

$

$

6 Apr.

12 Oct.

$

$

7 May

13 Nov.

$

$

8 June

14 Dec.

$

$

www.irs.gov/form1099h

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
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 2013. 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
any reimbursement credits paid to you for eligible months 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 monthly amount of any HCTC advance
payments or reimbursement credits you received. 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 2013 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).

Future Developments
For the latest information about developments related to Form 1099-H
and its instructions, such as legislation enacted after they were
published, go to www.irs.gov/form1099h.

VOID

CORRECTED

ISSUER'S/PROVIDER'S name, street address, city or town, province or state, 1 Amount of HCTC advance
payments
country, ZIP or foreign postal code, and telephone no.
$
2 No. of mos. HCTC
payments received

OMB No. 1545-1813

2013
Form 1099-H

ISSUER'S/PROVIDER'S federal identification number

RECIPIENT'S identification number

RECIPIENT'S name

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

Form

1099-H

3 Jan.

9 July

$

$

4 Feb.

10 Aug.

$

$

5 Mar.

11 Sept.

$

$

6 Apr.

12 Oct.

$

$

7 May

13 Nov.

$

$

8 June

14 Dec.

$

$

www.irs.gov/form1099h

Health Coverage
Tax Credit (HCTC)
Advance Payments

Copy C
For
Issuer/Provider
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2013 General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Issuer/Provider
General and specific form instructions are provided
separately. You should use the 2013 General
Instructions for Certain Information Returns and the
2013 Instructions for Forms 1099-H to complete 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, go to www.irs.gov/form1099h or call 1-800-TAXFORM (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, 2014. Copy 1 is furnished by the HCTC
Transaction Center.

File Copy A of this form with the IRS by
February 28, 2014. If you file electronically, the due date
is March 31, 2014. 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). Persons with a hearing or speech
disability with access to TTY/TDD equipment can 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.