Form 1099-LTC

2016

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 

2016 General 

Instructions for 

Certain 

Information 

Returns.

9393 VOID CORRECTED

www.irs.gov/form1099ltc

PAYER'S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no.

PAYER’S federal identification number POLICYHOLDER'S identification number

POLICYHOLDER'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal 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 taxpayer identification no. 

INSURED'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal 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

2016

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 or town, state or province, country, ZIP 

or foreign postal code, and telephone no.

PAYER’S federal identification number POLICYHOLDER'S identification number

POLICYHOLDER'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Gross long-term care 

benefits paid

$

2 Accelerated death benefits 

paid

$

3

Per 

diem

Reimbursed 

amount

INSURED'S taxpayer identification no.

INSURED'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

4 Qualified contract 

(optional)

5 (optional) Chronically ill

Terminally ill

Date certified

Form 1099-LTC (keep for your records) www.irs.gov/form1099ltc
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.

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.

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), adoption taxpayer identification number (ATIN), or 

employer identification number (EIN). However, the issuer has reported your 

complete identification number to the IRS.

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.

Future developments. For the latest developments related to Form 1099-LTC 

and its instructions, such as legislation enacted after they were published, go to

www.irs.gov/form1099ltc. 
 

Form 1099-LTC

2016

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 or town, state or province, country, ZIP 

or foreign postal code, and telephone no.

PAYER’S federal identification number POLICYHOLDER'S identification number

POLICYHOLDER'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Gross long-term care 

benefits paid

$

2 Accelerated death benefits 

paid

$

3

Per 

diem

Reimbursed 

amount

INSURED'S taxpayer identification no.

INSURED'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

4 Qualified contract 

(optional)

5 (optional) Chronically ill

Terminally ill

Date certified

Form 1099-LTC (keep for your records) www.irs.gov/form1099ltc
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), adoption taxpayer identification number 

(ATIN), or employer identification number (EIN). However, 

the issuer has reported your complete identification 

number to the IRS.

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 longterm care insurance contract.

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

terminally ill, and the latest date certified.

Future developments. For the latest developments related 

to Form 1099-LTC and its instructions, such as legislation 

enacted after they were published, go to www.irs.gov/

form1099ltc. 
 

Form 1099-LTC

2016

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 

2016 General 

Instructions for 

Certain 

Information 

Returns.

VOID CORRECTED

PAYER'S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no.

PAYER’S federal identification number POLICYHOLDER'S identification number

POLICYHOLDER'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Gross long-term care 

benefits paid

$

2 Accelerated death benefits 

paid

$

3

Per 

diem

Reimbursed 

amount

INSURED'S taxpayer identification no.

INSURED'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

4 Qualified contract 

(optional)

5 Check, if applicable: 

(optional)

Chronically ill

Terminally ill

Date certified

Form 1099-LTC www.irs.gov/form1099ltc
Instructions for Payer

To complete Form 1099-LTC, use:

• the 2016 General Instructions for Certain Information 

Returns, and

• the 2016 Instructions for Form 1099-LTC.

To order these instructions and additional forms, go 

to www.irs.gov/form1099ltc.

Due dates. Furnish Copy B of this form to the 

policyholder by January 31, 2017.

Furnish Copy C of this form to the insured by 

January 31, 2017.

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

2017. If you file electronically, the due date is March 31, 

2017. To file electronically, you must have software that 

generates a file according to the specifications in Pub. 

1220. 

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). Persons with a hearing or speech 

disability with access to TTY/TDD equipment can call 

304-579-4827 (not toll free).