Form 1099-H (2017 Draft 1099-H (2017 Draft Health coverage Tax Credit (HCTC) Advance Payments

Tax Forms & Publications
Work Request Notification (WRN)/Circulation
Product F1099 H
Title

Health Coverage Tax Credit (HCTC) Advance Payments

Tax year 2017

Processing year 2018

This is the 1st circulation of this product for your review and comments. This circulation can be used to support any necessary work
requests.
Authority for changes that may impact a Unified Work Request (UWR) (For changes, see Description of Major Changes below)

Signature of Approving Official

Circulation signature date

Melody G. Devoe

Digitally signed by Melody G. Devoe
DN: c=US, o=U.S. Government, ou=Department of the Treasury, ou=Internal Revenue Service,
ou=People, serialNumber= GH1LB, cn=Melody G. Devoe
Date: 2016.05.03 03:35:42 -0400

05/03/2016

Description of major changes (A description of changes to a form's instructions that may impact a UWR is also included, as applicable)
No major changes.

Comments: Comments are due 30 days after the date this circulation is signed and issued, unless a different date is specified here:
Comments should be sent via email to both the Tax Law Specialist and Reviewer listed below. We will accept comments after the due date, but may not
be able to consider any comments (timely or not) for this revision if implementing the comments would require a late UWR. If we need to make
significant changes based on comments or other new information received, we normally will issue a subsequent circulation of this product; otherwise,
these changes are final unless indicated otherwise in the Description of Major Changes.

Name of Tax Law Specialist OKSANA R. STOWBUNENKO

Name of Reviewer MELODY G DEVOE

Email address [email protected]

Email address [email protected]

Form 14216 (Rev. 6-2014)

Catalog Number 57440M

publish.no.irs.gov

Department of Treasury - Internal Revenue Service

7171

VOID

CORRECTED

ISSUER'S/PROVIDER'S name, street address, city or town, state or province, 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

2016

Health Coverage
Tax Credit (HCTC)
Advance Payments

17

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

3 Jan.

9 July

$

$

4 Feb.

10 Aug.

$

$

5 Mar.

11 Sept.

$

$

6 Apr.

12 Oct.

$

$

7 May

13 Nov.

$

$

8 June

14 Dec.

$

$

Copy A
For
Internal Revenue
Service Center
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2016 General 17
Instructions for
Certain Information
Returns.

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, state or province, 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

2016

Health Coverage
Tax Credit (HCTC)
Advance Payments

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, state or province, 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

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

17

Instructions for Recipient
This statement is provided to you because you received
Health Coverage Tax Credit (HCTC) advance payments
of your health coverage insurance premiums. These
advance payments were forwarded directly to your
health insurance provider. You are qualified to receive
advance payments if you were an eligible trade
adjustment assistance (TAA), Alternative TAA,
Reemployment TAA recipient, or a Pension Benefit
Guaranty Corporation (PBGC) pension payee. 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.

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.

VOID

CORRECTED

ISSUER'S/PROVIDER'S name, street address, city or town, state or province, 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

2016

Health Coverage
Tax Credit (HCTC)
Advance Payments

17

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, state or province, 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

Copy C
For
Issuer/Provider
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2016 General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

17

Instructions for Issuer/Provider
17
17

18

To complete Form 1099-H, use:
• the 2016 General Instructions for Certain Information
Returns, and
• the 2016 Instructions for Form 1099-H.
To order these instructions and additional forms, go to
www.irs.gov/form1099h.
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 recipient
by January 31, 2017.

File Copy A of this form with the IRS by
February 28, 2017. If you file electronically, the due date 18
is March 31, 2017. To file electronically, you must have April 2, 2018
software that generates a file according to the
specifications in Pub. 1220. The 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).