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

2008 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

Terminally ill

Chronically ill Qualified contract 5

(optional)

4 Check, if applicable:

(optional)

2008
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)

2008
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, for more information.

Per diem basis. This means the payments were made on a

periodic basis without regard to the actual expenses

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.

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)

2008
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 Account number. May show an account or other terminally ill, and the latest date certified. 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

2008 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

Terminally ill

Chronically ill Qualified contract 5

(optional)

4

2008

Check, if applicable:

(optional)
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 2008 General

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

and the 2008 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 2, 2009.

File Copy A of this form with the IRS by

March 2, 2009. If you file electronically, the due date is

March 31, 2009. To file electronically, you must have

software that generates a file according to the

specifications in Pub. 1220, Specifications for Filing

Forms 1098, 1099, 5498, and W-2G Electronically. IRS

does not provide a fill-in form option.

Printed on recycled paper

Furnish Copy C of this form to the insured by

February 2, 2009.

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.

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 304-267-3367 (not toll free). The hours of operation

are Monday through Friday from 8:30 a.m. to 4:30

p.m., Eastern time.