Form 1099-LS Reportable Life Insurance Sale

1616

VOID

Version A, Cycle 7
Dimensions: 7.3" x 3.5"
Only Red copy is not fillable

CORRECTED

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

1 Amount paid to payment
recipient

OMB No. 1545-0108

2019

INTERNAL USE ONLY
DRAFT AS OF
August 9, 2018
$

2 Date of sale

2018

Reportable Life
Insurance Sale

Form 1099-LS

ACQUIRER'S TIN

PAYMENT RECIPIENT'S TIN

PAYMENT RECIPIENT'S name

Copy A

Issuer's name

For
Internal Revenue

Acquirer's information contact entity name, street address, city
Service Center
or town, state or province, country, ZIP or foreign postal code,
File with Form 1096.
and telephone no. (if different from ACQUIRER)

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2018 General
Instructions for
Certain
Information
Returns.

Street address (including apt. no.)

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

1099-LS
Cat. No. 71383M
www.irs.gov/Form1099LS
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

2019

Version A, Cycle 7
Dimensions: 7.3" x 3.5"
Only Red copy is not fillable

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

1 Amount paid to payment
recipient

OMB No. 1545-0108

2019

INTERNAL USE ONLY
DRAFT AS OF
August 9, 2018
$

2 Date of sale

2018

Reportable Life
Insurance Sale

Form 1099-LS

ACQUIRER'S TIN

PAYMENT RECIPIENT'S TIN

Street address (including apt. no.)

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

1099-LS

Copy B

For Payment
Recipient

PAYMENT RECIPIENT'S name

Form

Issuer's name

(keep for your records)

Acquirer's information contact entity name, street address, city
or town, state or province, country, ZIP or foreign postal code,
This is important tax
and telephone no. (if different from ACQUIRER)
information and is being
furnished to the IRS. If
you are required to file a
return, a negligence
penalty or other
sanction may be
imposed on you if this
item is required to be
reported and the IRS
determines that it has
not been reported.
www.irs.gov/Form1099LS

Department of the Treasury - Internal Revenue Service

Version A, Cycle 7
Dimensions: 7.3" x 3.5"
Only Red copy is not fillable

Instructions for Payment Recipient
An acquirer of a life insurance contract or any interest in a life
insurance contract in a reportable policy sale under section
6050Y must give this form to you for payments made to you in
the reportable policy sale.
Payment Recipient's taxpayer identification number (TIN).
For your protection, this form may show only the last four
digits of your TIN (social security number (SSN), individual
taxpayer identification number (ITIN), adoption taxpayer
identification number (ATIN), or employer identification number
(EIN)). However, the acquirer has reported your complete TIN
to the IRS.
Policy number. Shows the policy number the life insurance
company assigned to the life insurance contract.

Box 1. Shows the amount paid to you in the reportable policy
sale under section 6050Y.
Box 2. Shows the date of sale.
Issuer's name. Shows the life insurance company that issued
the life insurance contract acquired in the reportable policy
sale under section 6050Y.
Acquirer's information contact name, address, and phone
number. Shows the contact information of the acquirer. If
blank, the contact information is the same as the ACQUIRER.
Future developments. For the latest developments related to
Form 1099-LS and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/Form1099LS.

INTERNAL USE ONLY
DRAFT AS OF
August 9, 2018

Version A, Cycle 7
Dimensions: 7.3" x 3.5"
Only Red copy is not fillable

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

1 Amount paid to payment
recipient (optional)

OMB No. 1545-0108

2019

INTERNAL USE ONLY
DRAFT AS OF
August 9, 2018
$

2 Date of sale

2018

Reportable Life
Insurance Sale

Form 1099-LS

ACQUIRER'S TIN

PAYMENT RECIPIENT'S TIN

Copy C

Issuer's name

For Issuer

PAYMENT RECIPIENT'S name

Acquirer's information contact entity name, street address, city
or town, state or province, country, ZIP or foreign postal code,
and telephone no. (if different from ACQUIRER)

Street address (including apt. no.)

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

1099-LS

(keep for your records)

www.irs.gov/Form1099LS

Copy C is
provided to you
for information
only. Only the
payment recipient is
required to
report this
information on
a tax return.

Department of the Treasury - Internal Revenue Service

Version A, Cycle 7
Dimensions: 7.3" x 3.5"
Only Red copy is not fillable

Instructions for Issuer
An acquirer of a life insurance contract or any interest in a
life insurance contract in a reportable policy sale under
section 6050Y must give this form to you to report the
acquisition.
If you are the issuer, Copy C is provided to you because
you have an information reporting obligation under section
6050Y(b). You must file a Form 1099-SB with respect to
the reportable policy sale under section 6050Y.
Payment Recipient's taxpayer identification number
(TIN). For the payment recipient's protection, this form may
show only the last four digits of the payment recipient's
TIN (social security number (SSN), individual taxpayer
identification number (ITIN), adoption taxpayer
identification number (ATIN), or employer identification
number (EIN)). However, the acquirer has reported the
payment recipient's complete TIN to the IRS.
Policy number. Shows the policy number assigned to the
life insurance contract acquired by the acquirer.

Box 1. This box may show the amount paid to the payment
recipient.
Box 2. Shows the date of sale.
Issuer's name. Shows your name as the life insurance
company that issued the life insurance contract acquired in
the reportable policy sale under section 6050Y.
Acquirer's information contact name, address, and
phone number. Shows the contact information of the
acquirer. If blank, the information is the same as
ACQUIRER.
Future developments. For the latest developments related
to Form 1099-LS and its instructions, such as legislation
enacted after they were published, go to www.irs.gov/
Form1099LS.

INTERNAL USE ONLY
DRAFT AS OF
August 9, 2018

VOID

Version A, Cycle 7
Dimensions: 7.3" x 3.5"
Only Red copy is not fillable

CORRECTED

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

1 Amount paid to payment
recipient

OMB No. 1545-0108

2019

INTERNAL USE ONLY
DRAFT AS OF
August 9, 2018
$

2 Date of sale

Reportable Life
Insurance Sale

2018

Form 1099-LS

ACQUIRER'S TIN

PAYMENT RECIPIENT'S TIN

Issuer's name

Copy D

For Acquirer

PAYMENT RECIPIENT'S name

Acquirer's information contact entity name, street address, city
or town, state or province, country, ZIP or foreign postal code,
and telephone no. (if different from ACQUIRER)

Street address (including apt. no.)

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

1099-LS

www.irs.gov/Form1099LS

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2018 General
Instructions for
Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

2019

2020

2019

Version A, Cycle 7
Dimensions: 7.3" x 3.5"
Only Red copy is not fillable

March 31,

Instructions for Acquirer
To complete Form 1099-LS, use:
• The 2018 General Instructions for Certain Information
Returns, and
• The 2018 Instructions for Form 1099-LS.
To get or to order these instructions, go to
www.irs.gov/Form1099LS.
Due dates. Furnish Copy B of this form to the
policyholder by January 31, 2019.
Furnish Copy C of this form to the issuer no later than
January 15, 2019.

File Copy A of this form with the IRS by February 28,
2019. If you file electronically, the due date is April 1,
2019. To file electronically, you must have software that
generates a file according to the specifications in Pub.
1220. The IRS does not provide a fill-in form option for
Copy A.
Need help? If you have questions about reporting on
Form 1099-LS, call the information reporting customer
service site toll free at 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).

INTERNAL USE ONLY
DRAFT AS OF
August 9, 2018
2020