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

POLICYHOLDER’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form 1099-LTC Department of the Treasury - Internal R

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on T

3

File wit

Cat. No. 23021Z

Intern

Ser

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

$

Fo

an

R

No

2

Ins

Terminally ill 

Chronically ill Qualified contract 5

(optional)

4 Check, if applicable:

(optional)
PAYER’S federal identification number POLICYHOLDER’S identification number

POLICYHOLDER’S name

Street address (including apt. no.)

This 

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City, state, and ZIP code

Account number (see instructions)

Form 1099-LTC Department of the Treasury - Internal R

3

(keep for your records)

For P

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)
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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. Generally, 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. 525 and Form 8853, and its instructions for more

information.

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

insurance contract during the year.

Box 2. Shows the gross accelerated death benefits paid 

year.

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

basis or was reimbursement of actual long-term care ex

the insured was terminally ill, this box may not be chec

Box 4. May show if the benefits were from a qualified lo

insurance contract.

Box 5. May show if the insured was certified chronically 

terminally ill, and the latest date certified.

Account number. May show an account or other uniqu

payer assigned to distinguish your account.

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

periodic basis without regard to the actual expenses incurred during

the period to which the payments relate.

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However, the issuer has reported your complete identifi

number to the IRS, and, where applicable, to state and/

governments.
PAYER’S federal identification number POLICYHOLDER’S identification number

POLICYHOLDER’S name

Street address (including apt. no.)

pr

f

p

City, state, and ZIP code

Account number (see instructions)

Form 1099-LTC Department of the Treasury - Internal R

3

(keep for your records)

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)
beesayes cude bobees you eceed

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.

long-term care insurance contract during the 

Box 2. Shows the gross accelerated death b

paid during the year.

Box 3. Shows if the amount in box 1 or 2 w

a per diem basis or was reimbursement of a

long-term care expenses. If you are terminal

box may not be checked.

Box 4. May show if the benefits were from a 

long-term care insurance contract.

Box 5. May show if you were certified chron

terminally ill, and the latest date certified.

Insured’s identification number. For your protection,

this form may show only the last four digits of your

social security number (SSN), individual taxpayer

identification number (ITIN), or adoption taxpayer

identification number (ATIN). However, the issuer has

reported your complete identification number to the

IRS, and, where applicable, to state and/or local

governments.
PAYER’S federal identification number POLICYHOLDER’S identification number

POLICYHOLDER’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form 1099-LTC Department of the Treasury - Internal R

3

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

$

Fo

an

R

No

2

Ins

Terminally ill

Chronically ill Qualified contract 5

(optional)

4 Check, if applicable:

(optional)
general instructions gives a quick guide to which form

must be filed to report a particular payment. To order

these instructions and additional forms, visit the IRS

website at www.irs.gov or call 1-800-TAX-FORM

(1-800-829-3676).

Due dates. Furnish Copy B of this form to the

policyholder by January 31, 2011.

, y

have software that generates a file according 

specifications in Pub. 1220, Specifications fo

Forms 1098, 1099, 3921, 3922, 5498, 8935, 

Electronically. IRS does not provide a fill-in f

option.

Caution: Because paper forms are scanned during

processing, you cannot file Forms 1096, 1098, 1099,

3921, 3922, or 5498 that you print from the IRS

website.

Need help? If you have questions about rep

Form 1099-LTC, call the information reportin

customer service site toll free at 1-866-455-7

304-263-8700 (not toll free). For TTY/TDD eq

call 304-579-4827 (not toll free). The hours o

are Monday through Friday from 8:30 a.m. to

4:30 p.m., Eastern time.