Form 1099-LS Reportable Life Insurance Sale

Attention:
Copy A of this form is provided for informational purposes only. Copy A appears in red,
similar to the official IRS form. The official printed version of Copy A of this IRS form is
scannable, but the online version of it, printed from this website, is not. Do not print and file
copy A downloaded from this website; a penalty may be imposed for filing with the IRS
information return forms that can’t be scanned. See part O in the current General
Instructions for Certain Information Returns, available at www.irs.gov/form1099, for more
information about penalties.
Please note that Copy B and other copies of this form, which appear in black, may be
downloaded and printed and used to satisfy the requirement to provide the information to
the recipient.
To order official IRS information returns, which include a scannable Copy A for filing with
the IRS and all other applicable copies of the form, visit www.IRS.gov/orderforms. Click on
Employer and Information Returns, and we’ll mail you the forms you request and their
instructions, as well as any publications you may order.
Information returns may also be filed electronically using the IRS Filing Information Returns
Electronically (FIRE) system (visit www.IRS.gov/FIRE) or the IRS Affordable Care Act
Information Returns (AIR) program (visit www.IRS.gov/AIR).
See IRS Publications 1141, 1167, and 1179 for more information about printing these tax
forms.

1616

VOID

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. 1545-2281

$

Form

2 Date of sale

(Rev. December 2019)

1099-LS

Reportable Life
Insurance Sale

For calendar year

20
ACQUIRER’S TIN

PAYMENT RECIPIENT’S TIN

PAYMENT RECIPIENT’S name

Acquirer’s information contact 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 (Rev. 12-2019)

Copy A

Issuer’s name

Cat. No. 71383M

www.irs.gov/Form1099LS

For
Internal Revenue
Service Center

File with Form 1096.

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

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

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. 1545-2281

$

Form

2 Date of sale

(Rev. December 2019)

1099-LS

Reportable Life
Insurance Sale

For calendar year

20
ACQUIRER’S TIN

PAYMENT RECIPIENT’S TIN

PAYMENT RECIPIENT’S name

Acquirer’s information contact 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 (Rev. 12-2019)

Copy B

Issuer’s name

(keep for your records)

www.irs.gov/Form1099LS

For Payment
Recipient
This is important tax
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.

Department of the Treasury - Internal Revenue Service

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 insurance company that bears the
risk with respect to the life insurance contract on the date a
Form 1099-LS is required to be furnished to that issuer.
Generally, this will be the life insurance company responsible
for administering the contract, including paying death benefits
under the life insurance contract.
Acquirer’s information contact name, address, and phone
number. Shows the contact information of the acquirer. The
contact information provided will give you direct access to a
person who can answer questions about this form. 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.

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. 1545-2281

$

Form

2 Date of sale

(Rev. December 2019)

1099-LS

Reportable Life
Insurance Sale

For calendar year

20
ACQUIRER’S TIN

PAYMENT RECIPIENT’S TIN

Copy C

Issuer’s name

For Issuer
PAYMENT RECIPIENT’S name

Acquirer’s information contact 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 (Rev. 12-2019)

(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

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 from the payment
recipient.

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 insurance
company that bears the risk with respect to the life
insurance contract on the date a Form 1099-LS is required
to be furnished to you.
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.

VOID

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. 1545-2281

$

Form

2 Date of sale

(Rev. December 2019)

1099-LS

Reportable Life
Insurance Sale

For calendar year

20
ACQUIRER’S TIN

PAYMENT RECIPIENT’S TIN

Issuer’s name

Copy D
For Acquirer

PAYMENT RECIPIENT’S name

Acquirer’s information contact 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 (Rev. 12-2019)

www.irs.gov/Form1099LS

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

Department of the Treasury - Internal Revenue Service

Instructions for Acquirer
To complete Form 1099-LS, use:
• The current General Instructions for Certain
Information Returns, and
• The current Instructions for Form 1099-LS.
To get or to order these instructions, go to
www.irs.gov/Form1099LS.
Filing and furnishing. For filing and furnishing
instructions, including due dates, and to request filing or
furnishing extensions, see the current General
Instructions for Certain Information Returns.

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).