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 (see instructions)

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

2011 General

Instructions for

Certain

Information

Terminally ill Returns.

Chronically ill Qualified contract 5

(optional)

4 Check, if applicable:

(optional)

2011
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 (see instructions)

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)

2011
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 and Form 8853, and its instructions for more

information.

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 if the amount in box 1 or 2 was paid on a per diem

basis or was reimbursement of actual long-term care expenses. If

the insured was terminally ill, this box may not be checked.

Box 4. May show if the benefits were from a qualified long-term care

insurance contract.

Box 5. May show if the insured was certified chronically ill or

terminally ill, and the latest date certified.

Account number. May show an account or other unique number the

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.
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 (see instructions)

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)

2011
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 if the amount in box 1 or 2 was paid on

a per diem basis or was reimbursement of actual

long-term care expenses. If you are terminally ill, this

box may not be checked.

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

long-term care insurance contract.

Box 5. May show if you were certified chronically ill or

terminally ill, and the latest date certified. Account number. May show an account or other

unique number the payer assigned to distinguish your

account.
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 (see instructions)

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

2011 General

Instructions for

Certain

Information

Returns.

Terminally ill

Chronically ill Qualified contract 5

(optional)

4 Check, if applicable:

(optional)

2011
Instructions for Payer

General and specific form instructions are provided as

separate products. The products you should use to

complete Form 1099-LTC are the 2011 General

Instructions for Certain Information Returns and the

2011 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 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, 2012.

File Copy A of this form with the IRS by

February 28, 2012. If you file electronically, the due

date is April 2, 2012. To file electronically, you must

have software that generates a file according to the

specifications in Pub. 1220, Specifications for Filing

Forms 1097, 1098, 1099, 3921, 3922, 5498, 8935, and

W-2G Electronically. IRS does not provide a fill-in form

option.

Furnish Copy C of this form to the insured by

January 31, 2012.

Caution: Because paper forms are scanned during

processing, you cannot file Forms 1096, 1097, 1098,

1099, 3921, 3922, or 5498 that you print from the IRS

website.

Need help? If you have questions about reporting on

Form 1099-LTC, call the information reporting

customer service site toll free at 1-866-455-7438 or

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

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

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

4:30 p.m., Eastern time.