Form 1099-LTC

2012

Cat. No. 23021Z

Long-Term Care and 

Accelerated Death 

Benefits

Copy A

For 

Internal Revenue 

Service Center

Department of the Treasury - Internal Revenue Service

File with Form 1096. 

OMB No. 1545-1519

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2012 General 

Instructions for 

Certain 

Information 

Returns.

9393 VOID CORRECTED

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

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)

1 Gross long-term care 

benefits paid

$

2 Accelerated death 

benefits paid

$

3 Check one:

Per 

diem

Reimbursed 

amount

INSURED'S social security no.

INSURED'S name

Street address (including apt. no.)

City, state, and ZIP code

4 Qualified contract 

(optional)

5 Check, if applicable: 

(optional)

Chronically ill

Terminally ill

Date certified

Form 1099-LTC

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
Form 1099-LTC

2012

Long-Term Care and 

Accelerated Death 

Benefits

Copy B

For Policyholder

Department of the Treasury - Internal Revenue Service

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.

OMB No. 1545-1519

CORRECTED (if checked)

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

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)

1 Gross long-term care 

benefits paid

$

2 Accelerated death 

benefits paid

$

3

Per 

diem

Reimbursed 

amount

INSURED'S social security no.

INSURED'S name

Street address (including apt. no.)

City, state, and ZIP code

4 Qualified contract 

(optional)

5 (optional) Chronically ill

Terminally ill

Date certified

Form 1099-LTC (keep for your records)
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 longterm 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.

Policyholder'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.

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.

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.

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.

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

assigned to distinguish your account.

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.
Form 1099-LTC

2012

Long-Term Care and 

Accelerated Death 

Benefits

Copy C

For Insured

Department of the Treasury - Internal Revenue Service

Copy C is 

provided to you 

for information 

only. Only the 

policyholder is 

required to 

report this 

information on 

a tax return.

OMB No. 1545-1519

CORRECTED (if checked)

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

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)

1 Gross long-term care 

benefits paid

$

2 Accelerated death 

benefits paid

$

3

Per 

diem

Reimbursed 

amount

INSURED'S social security no.

INSURED'S name

Street address (including apt. no.)

City, state, and ZIP code

4 Qualified contract 

(optional)

5 (optional) Chronically ill

Terminally ill

Date certified

Form 1099-LTC (keep for your records)
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.

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.

Account number. May show an account or other 

unique number the payer assigned to distinguish your 

account.

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.
Form 1099-LTC

2012

Long-Term Care and 

Accelerated Death 

Benefits

Copy D

For Payer

Department of the Treasury - Internal Revenue Service

OMB No. 1545-1519

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2012 General 

Instructions for 

Certain 

Information 

Returns.

VOID CORRECTED

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

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)

1 Gross long-term care 

benefits paid

$

2 Accelerated death 

benefits paid

$

3

Per 

diem

Reimbursed 

amount

INSURED'S social security no.

INSURED'S name

Street address (including apt. no.)

City, state, and ZIP code

4 Qualified contract 

(optional)

5 Check, if applicable: 

(optional)

Chronically ill

Terminally ill

Date certified

Form 1099-LTC
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 2012 General 

Instructions for Certain Information Returns and the 

2012 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).

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.

Due dates. Furnish Copy B of this form to the 

policyholder by January 31, 2013.

Furnish Copy C of this form to the insured by January 

31, 2013.

File Copy A of this form with the IRS by February 28, 

2013. If you file electronically, the due date is April 1, 

2013. 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.

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.