0593 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.) For Paperwork

Reduction Act Notice

and instructions for

completing this form,

see the

1997 Instructions for

Forms 1099, 1098,

5498, and W-2G.

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

PAYER’S name, street address, city, state, and ZIP code

2

3

File with Form 1096.

Cat. No. 23021Z

For

Internal Revenue

Service Center

Form 1099-LTC

97

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

4

(optional)
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, and ZIP code

2

3

(Keep for your records.)

For Policyholder

Form 1099-LTC

97

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

4

(optional)
Instructions for Policyholder

A payer, such as an insurance company, 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 paid

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, for more information.

Per diem basis.—This means payments 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 this calendar year.

Box 2.—Shows the gross accelerated death benefits paid

during this calendar year.

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

a per diem basis or was reimbursement of actual

long-term care expenses.

Box 4.—Shows whether the insured was certified

chronically ill or terminally ill, and the 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, and ZIP code

2

3

(Keep for your records.)

For Insured

Form 1099-LTC

97

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

4

(optional)
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 this calendar year.

Box 2.—Shows the gross accelerated death benefits paid

during this calendar year.

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

a per diem basis or was reimbursement of actual

long-term care expenses.

Box 4.—Shows whether you were certified chronically ill

or terminally ill, and the 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, and ZIP code

2

3

For Payer

Form 1099-LTC

97

Per

diem

Reimbursed

amount

INSURED’S social security no.

INSURED’S name

Street address (including apt. no.)

City, state, and ZIP code

VOID CORRECTED

For Paperwork

Reduction Act

Notice and

instructions for

completing this

form, see the

1997 Instructions

for Forms 1099,

1098, 5498,

and W-2G.

Date certified

$

$

Terminally

ill

Chronically

ill

4

(optional)
Payers, Please Note—

Specific information needed to complete this form and

other forms in the 1099 series is given in the 1997

Instructions for Forms 1099, 1098, 5498, and W-2G.

A chart in those instructions gives a quick guide to

which form must be filed to report a particular

payment. You can order those instructions and

additional forms by calling 1-800-TAX-FORM

(1-800-829-3676).

Furnish Copy B of this form to the policyholder by

February 2, 1998.

File Copy A of this form with the IRS by March 2,

1998.

Furnish Copy C of this form to the insured by

February 2, 1998.