9393 VOID CORRECTED

OMB No. 1545-1519

Long-Term Care and

Accelerated Death

Benefits

PAYER’S Federal identification number POLICYHOLDER’S identification number Check one:

Gross long-term care

benefits paid

1

Copy A

POLICYHOLDER’S name

Accelerated death

benefits paid

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 1099-LTC 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

PAYER’S name, street address, city, state, ZIP code, and telephone no.

2

3

File with Form 1096.

Cat. No. 23021Z

For

Internal Revenue

Service Center

Form 1099-LTC

Per

diem

Reimbursed

amount

INSURED’S social security no.

INSURED’S name

Street address (including apt. no.)

City, state, and ZIP code

Date certified

$

$

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2003 General

Instructions for

Forms 1099, 1098,

Terminally ill 5498, and W-2G.

Chronically ill Qualified contract 5

(optional)

4 Check, if applicable:

(optional)

2003
CORRECTED (if checked)

OMB No. 1545-1519

Long-Term Care and

Accelerated Death

Benefits

PAYER’S Federal identification number POLICYHOLDER’S identification number

Gross long-term care

benefits paid

1

Copy B

POLICYHOLDER’S name

Accelerated death

benefits paid

Street address (including apt. no.)

This is important tax

information and is being

furnished to the Internal

Revenue Service. 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.

City, state, and ZIP code

Account number (optional)

Form 1099-LTC Department of the Treasury - Internal Revenue Service

PAYER’S name, street address, city, state, ZIP code, and telephone no.

2

3

(keep for your records)

For Policyholder

Form 1099-LTC

Per

diem

Reimbursed

amount

INSURED’S social security no.

INSURED’S name

Street address (including apt. no.)

City, state, and ZIP code

Date certified

$

$

Terminally ill

Chronically ill Qualified contract 5

(optional)

4 (optional)

2003
Instructions for Policyholder

A payer, such as an insurance company or a viatical

settlement provider, must give this form to you for payments

made under a long-term care insurance contract or for

accelerated death benefits. Payments include those made

directly to you (or to the insured) and those made to third

parties.

A long-term care insurance contract provides coverage of

expenses for long-term care services for an individual who

has been certified by a licensed health care practitioner as

chronically ill. A life insurance company or viatical settlement

provider may pay accelerated death benefits if the insured

has been certified by either a physician as terminally ill or by

a licensed health care practitioner as chronically ill.

Long-term care insurance contract. Amounts received

under a qualified long-term care insurance contract are

excluded from your income. However, if payments are made

on a per diem basis, the amount you may exclude is limited.

The per diem exclusion limit must be allocated among all

policyholders who own qualified long-term care insurance

contracts for the same insured. See Pub. 502, Medical and

Dental Expenses, and Form 8853, Archer MSAs and

Long-Term Care Insurance Contracts, for more information.

Per diem basis. This means the payments were made on a

periodic basis without regard to the actual expenses incurred

during the period to which the payments relate.

Accelerated death benefits. Amounts paid as accelerated

death benefits are fully excludable from your income if the

insured has been certified by a physician as terminally ill.

Accelerated death benefits paid on behalf of individuals who

are certified as chronically ill are excludable from income to

the same extent they would be if paid under a qualified

long-term care insurance contract.

Box 1. Shows the gross benefits paid under a long-term care

insurance contract during the year.

Box 2. Shows the gross accelerated death benefits paid

during the year.

Box 3. Shows whether the amount in box 1 or 2 was paid on

a per diem basis or was reimbursement of actual long-term

care expenses. This box may not be marked if the insured

was terminally ill.

Box 4. May show whether the benefits were from a qualified

long-term care insurance contract.

Box 5. May show whether the insured was certified

chronically ill or terminally ill, and the latest date certified.
CORRECTED (if checked)

OMB No. 1545-1519

Long-Term Care and

Accelerated Death

Benefits

PAYER’S Federal identification number POLICYHOLDER’S identification number

Gross long-term care

benefits paid

1

Copy C

POLICYHOLDER’S name

Accelerated death

benefits paid

Street address (including apt. no.)

Copy C is

provided to you

for information

only. Only the

policyholder is

required to

report this

information on

a tax return.

City, state, and ZIP code

Account number (optional)

Form 1099-LTC Department of the Treasury - Internal Revenue Service

PAYER’S name, street address, city, state, ZIP code, and telephone no.

2

3

(keep for your records)

For Insured

Form 1099-LTC

Per

diem

Reimbursed

amount

INSURED’S social security no.

INSURED’S name

Street address (including apt. no.)

City, state, and ZIP code

$

$

Date certified

Terminally ill

Chronically ill Qualified contract 5

(optional)

4 (optional)

2003
Instructions for Insured

A payer, such as an insurance company or a viatical

settlement provider, must give this form to you and to the

policyholder for payments made under a long-term care

insurance contract or for accelerated death benefits.

Payments include both benefits you received directly and

expenses paid on your behalf to third parties.

If you are the insured but are not the policyholder, Copy

C is provided to you for information only because these

payments are not taxable to you. If you are also the

policyholder, you should receive Copy B.

Box 1. Shows the gross benefits paid under a long-term

care insurance contract during the year.

Box 2. Shows the gross accelerated death benefits paid

during the year.

Box 3. Shows whether the amount in box 1 or 2 was paid

on a per diem basis or was reimbursement of actual

long-term care expenses. This box may not be marked if

you are terminally ill.

Box 4. May show whether the benefits were from a

qualified long-term care insurance contract.

Box 5. May show whether you were certified chronically ill

or terminally ill, and the latest date certified.
OMB No. 1545-1519

Long-Term Care and

Accelerated Death

Benefits

PAYER’S Federal identification number POLICYHOLDER’S identification number

Gross long-term care

benefits paid

1

Copy D

POLICYHOLDER’S name

Accelerated death

benefits paid

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 1099-LTC Department of the Treasury - Internal Revenue Service

PAYER’S name, street address, city, state, ZIP code, and telephone no.

2

3

For Payer

Form 1099-LTC

Per

diem

Reimbursed

amount

INSURED’S social security no.

INSURED’S name

Street address (including apt. no.)

City, state, and ZIP code

VOID CORRECTED

Date certified

$

$

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2003 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

Terminally ill

Chronically ill Qualified contract 5

(optional)

4 Check, if applicable:

(optional)

2003
Instructions for Payers

General and specific form instructions are provided as

separate products. The products you should use for

2003 are the General Instructions for Forms 1099,

1098, 5498, and W-2G and the separate specific

instructions for each information return you file.

Specific information needed to complete this form is

given in the 2003 Instructions for Form 1099-LTC. 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, call 1-800-TAX-FORM (1-800-829-3676).

Due dates. Furnish Copy B of this form to the

policyholder by February 2, 2004.

File Copy A of this form with the IRS by

March 1, 2004. If you file electronically, the due date is

March 31, 2004.

Furnish Copy C of this form to the insured by

February 2, 2004.

Caution: Because the IRS processes paper forms by

machine (optical character recognition equipment), you

cannot file with the IRS Forms 1096, 1098, 1099, or

5498 that you print from the IRS Web Site.
Note: Self Duplicating, Carbon Paper Not Required