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

9090

VOID

CORRECTED

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

1 Amount of HCTC advance
payments
$

OMB No. 1545-1813

1099-H

2 No. of mos. HCTC
payments received

Form
(Rev. January 2022)
For calendar year

3 Jan.

9 July

$

$

4 Feb.

10 Aug.

20
ISSUER'S/PROVIDER'S TIN

RECIPIENT'S TIN

RECIPIENT'S name

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

Form 1099-H (Rev. 1-2022)

Cat. No. 34912D

$

$

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 A
For
Internal Revenue
Service Center
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)
ISSUER'S/PROVIDER'S name, street address, city or town, state or
province, country, ZIP or foreign postal code, and telephone no.

1 Amount of HCTC advance
payments
$
2 No. of mos. of HCTC advance
payments and reimbursement
credits paid to you

OMB No. 1545-1813

ISSUER'S/PROVIDER'S TIN

3 Jan.

9 July

1099-H

Form
(Rev. January 2022)
For calendar year

20
RECIPIENT'S TIN

RECIPIENT'S name

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

Form 1099-H (Rev. 1-2022)

(keep for your records)

$

$

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
IRS.

Department of the Treasury - Internal Revenue Service

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) recipient, an Alternative
TAA (ATAA) recipient, a Reemployment TAA (RTAA)
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,
1040-SR, 1040-NR, 1040-SS, or 1040-PR.
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), or
adoption taxpayer identification number (ATIN)).

However, the issuer has reported your complete TIN to
the IRS.
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.
Free File Program. Go to www.irs.gov/FreeFile to see if
you qualify for no-cost online federal tax preparation,
e-filing, and direct deposit or payment options.

VOID

CORRECTED

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

1 Amount of HCTC advance
payments
$

OMB No. 1545-1813

1099-H

2 No. of mos. HCTC
payments received

Form
(Rev. January 2022)
For calendar year

3 Jan.

9 July

20
ISSUER'S/PROVIDER'S TIN

RECIPIENT'S TIN

RECIPIENT'S name

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

Form

1099-H (Rev. 1-2022)

$

$

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
current General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Issuer/Provider
To complete Form 1099-H, use:
• The current General Instructions for Certain
Information Returns, and
• The current Instructions for Form 1099-H.
To order these instructions and additional forms, go to
www.irs.gov/EmployerForms.
Filing and furnishing. For filing and furnishing
instructions, including due dates, and requesting filing
or furnishing extensions, see the current General
Instructions for Certain Information Returns.

Need help? If you have questions about reporting on
Form 1099-H, 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).