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

2004 General

Instructions for

Forms 1099, 1098,

Terminally ill 5498, and W-2G.

Chronically ill Qualified contract 5

(optional)

4 Check, if applicable:

(optional)

2004
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)

2004
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. 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 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.
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)

2004
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.
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

2004 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

Terminally ill

Chronically ill Qualified contract 5

(optional)

4 Check, if applicable:

(optional)

2004
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 2004 General

Instructions for Form 1099, 1098, 5498, and W-2G,

and the separate specific instructions, 2004

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 January 31, 2005.

File Copy A of this form with the IRS by

February 28, 2005. If you file electronically, the due

date is March 31, 2005.

Furnish Copy C of this form to the insured by

January 31, 2005.

Caution: Because paper forms are scanned during

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

5498 that you download and print from the IRS

website.
Note: Self Duplicating, Carbon Paper Not Required