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

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

Cat. No. 23021Z

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 5

2001

Copy A

For

Internal Revenue

Service Center

File with Form 1096.

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2001 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

Qualified contract

(optional)

4 Check, if applicable:

(optional)

Note: Self Duplicating, Carbon Paper Not Required
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

$

$

2001

Date certified

Terminally ill

Chronically ill Qualified contract 5

(optional)

4 (optional)
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. 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, Medical Savings Accounts

and Long-Term Care Insurance Contracts, 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 the year.

Box 2. Shows the gross accelerated death benefits paid

during the year.

Box 3. Shows whether the amount in box 1 or 2 was paid on

a per diem basis or was reimbursement of actual long-term

care expenses. This box may not be marked if the insured

was terminally ill.

Box 5. May show whether the insured was certified

chronically ill or terminally ill, and the latest date certified.

Box 4. May show whether the benefits were from a qualified

long-term care insurance contract.
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

$

$

2001

Date certified

Terminally ill

Chronically ill Qualified contract 5

(optional)

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 the year.

Box 2. Shows the gross accelerated death benefits paid

during the year.

Box 3. Shows whether the amount in box 1 or 2 was paid

on a per diem basis or was reimbursement of actual

long-term care expenses. This box may not be marked if

you are terminally ill.

Box 5. May show whether you were certified chronically ill

or terminally ill, and the latest date certified.

Box 4. May show whether the benefits were from a

qualified long-term care insurance contract.
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

$

$

2001

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2001 General

Instructions for

Forms 1099,

1098, 5498,

Date certified and W-2G.

Terminally ill

Chronically ill Qualified contract 5

(optional)

4 Check, if applicable:

(optional)
Payers, Please Note—

To help make it easier for you to get only the

information you need to complete the Forms 1099,

1098, 5498, and W-2G you file, we provide general

and specific form instructions as separate products.

The products you should use for 2001 are the General

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

which contain general information concerning Form

1099-LTC and other forms in the 1099 series, and the

separate specific instructions for each information

return you file. Specific information needed to

complete this form is given in the 2001 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. You can order those

instructions and additional forms by calling

1-800-TAX-FORM (1-800-829-3676). You can also get

forms and instructions from the IRS’s Internet Web Site

at www.irs.gov.

Due dates. Furnish Copy B of this form to the

policyholder by January 31, 2002.

File Copy A of this form with the IRS by

February 28, 2002. If you file electronically, the due

date is April 1, 2002.

Furnish Copy C of this form to the insured by

January 31, 2002.

Caution: Because the IRS processes paper forms by

machine (optical character recognition equipment), you

cannot file with the IRS Forms 1096, 1098, 1099, or

5498 that you print from the IRS’s Internet Web Site.