9393 VOID CORRECTED

OMB No. 1545-1519

Long

Ac

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

Gross long-term care

benefits paid

1

POLICYHOLDER’S name

Accelerated death

benefits paid

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form 1099-LTC Department of the Treasury - In

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

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

2

3

F

Cat. No. 23021Z

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 Check, if applicable:

(optional)

2009
CORRECTED (if checked)

OMB No. 1545-1519

Long

Ac

PAYER’S federal identification number POLICYHOLDER’S identification number

Gross long-term care

benefits paid

1

POLICYHOLDER’S name

Accelerated death

benefits paid

Street address (including apt. no.)

i

f

City, state, and ZIP code

Account number (see instructions)

Form 1099-LTC Department of the Treasury - In

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

2

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)

2009
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. 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, Taxable and Nontaxable Income, and Form 8853,

Archer MSAs and Long-Term Care Insurance Contracts, and its

instructions for more information.

Accelerated death benefits. Amounts paid as a

benefits are fully excludable from your income if 

been certified by a physician as terminally ill. Acc

benefits paid on behalf of individuals who are ce

ill are excludable from income to the same exten

paid under a qualified long-term care insurance c

Box 1. Shows the gross benefits paid under a lo

insurance contract during the year.

Box 2. Shows the gross accelerated death benef

year.

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

basis or was reimbursement of actual long-term 

the insured was terminally ill, this box may not be 

Box 4. May show if the benefits were from a qua

insurance contract.

Box 5. May show if the insured was certified chr

terminally ill, and the latest date certified.

Account number. May show an account or othe

payer assigned to distinguish your account.

Per diem basis. This means the payments were 

periodic basis without regard to the actual expen

the period to which the payments relate.
CORRECTED (if checked)

OMB No. 1545-1519

Long

Ac

PAYER’S federal identification number POLICYHOLDER’S identification number

Gross long-term care

benefits paid

1

POLICYHOLDER’S name

Accelerated death

benefits paid

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form 1099-LTC Department of the Treasury - In

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

2

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)

2009
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 u

long-term care insurance contract durin

Box 2. Shows the gross accelerated de

paid during the year.

Box 3. Shows if the amount in box 1 o

a per diem basis or was reimbursemen

long-term care expenses. If you are ter

box may not be checked.

Box 4. May show if the benefits were f

long-term care insurance contract.

Box 5. May show if you were certified c

terminally ill, and the latest date certifie

Account number. May show an account or other

unique number the payer assigned to distinguish your

account.
OMB No. 1545-1519

Long

Ac

PAYER’S federal identification number POLICYHOLDER’S identification number

Gross long-term care

benefits paid

1

POLICYHOLDER’S name

Accelerated death

benefits paid

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form 1099-LTC Department of the Treasury - In

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

2

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

VOID CORRECTED

Date certified

$

$

Terminally ill

Chronically ill Qualified contract 5

(optional)

4 Check, if applicable:

(optional)

2009
Instructions for Payers

General and specific form instructions are provided as

separate products. The products you should use to

complete Form 1099-LTC are the 2009 General

Instructions for Forms 1099, 1098, 3921, 3922, 5498,

and W-2G and the 2009 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, 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 February 1, 2010.

File Copy A of this form with the IRS 

March 1, 2010. If you file electronically, 

March 31, 2010. To file electronically, y

software that generates a file according 

specifications in Pub. 1220, Specificatio

Forms 1098, 1099, 3921, 3922, 5498, a

Electronically. IRS does not provide a f

option.

Printed on recycled paper

Furnish Copy C of this form to the in

February 1, 2010.

Caution: Because paper forms are scanned during

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

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

website.

Need help? If you have questions abou

Form 1099-LTC, call the information re

customer service site toll free at 1-866-

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

call 304-267-3367 (not toll free).