9090                    VOID                         CORRECTED
ISSUER'S/PROVIDER'S name, street address, city or town, state or         1 Amount of HCTC advance OMB No. 1545-1813
province, country, ZIP or foreign postal code, and telephone no.          payments                 Form 1099-H           Health Coverage 
                                                                         $
                                                                         2 No. of mos. HCTC       (Rev. January 2022)    Tax Credit (HCTC) 
                                                                          payments received        For calendar year     Advance Payments
                                                                                                    20
ISSUER'S/PROVIDER'S TIN             RECIPIENT'S TIN                      3 Jan.                   9 July                 Copy A
                                                                         $                        $                      For 
RECIPIENT'S name                                                         4 Feb.                   10 Aug.                Internal Revenue 
                                                                         $                        $                      Service Center
                                                                         5 Mar.                   11 Sept.
                                                                         $                        $                      For Privacy Act 
Street address (including apt. no.)                                      6 Apr.                   12 Oct.                and Paperwork 
                                                                         $                        $                      Reduction Act 
City or town, state or province, country, and ZIP or foreign postal code 7 May                    13 Nov.                Notice, see the 
                                                                                                                         current General 
                                                                         $                        $                      Instructions for 
                                                                         8 June                   14 Dec.                Certain Information 
                                                                         $                        $                      Returns.
Form 1099-H (Rev. 1-2022)           Cat. No. 34912D                        www.irs.gov/Form1099H    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

                                                                 CORRECTED (if checked)
ISSUER'S/PROVIDER'S name, street address, city or town, state or         1 Amount of HCTC advance      OMB No. 1545-1813
province, country, ZIP or foreign postal code, and telephone no.           payments                     Form 1099-H           Health Coverage 
                                                                         $
                                                                         2 No. of mos. of HCTC advance (Rev. January 2022)    Tax Credit (HCTC) 
                                                                           payments and reimbursement 
                                                                           credits paid to you          For calendar year     Advance Payments
                                                                                                             20
ISSUER'S/PROVIDER'S TIN             RECIPIENT'S TIN                      3 Jan.                        9 July
                                                                         $                             $
RECIPIENT'S name                                                         4 Feb.                        10 Aug.                Copy B
                                                                         $                             $
                                                                                                                              For Recipient
                                                                         5 Mar.                        11 Sept.
                                                                         $                             $                      This is important 
Street address (including apt. no.)                                      6 Apr.                        12 Oct.                tax information 
                                                                                                                              and is being 
                                                                         $                             $                      furnished to the 
City or town, state or province, country, and ZIP or foreign postal code 7 May                         13 Nov.                IRS.
                                                                         $                             $
                                                                         8 June                        14 Dec.
                                                                         $                             $
Form 1099-H (Rev. 1-2022)           (keep for your records)                www.irs.gov/Form1099H         Department of the Treasury - Internal Revenue Service

Instructions for Recipient
This statement is provided to you because you received  However, the issuer has reported your complete TIN to 
Health Coverage Tax Credit (HCTC) advance payments      the IRS.
of your health coverage insurance premiums. These       Box 1. Shows the total amount of HCTC advance 
advance payments were forwarded directly to your        payments of qualified health insurance costs that were 
health insurance provider. You are qualified to receive made on your behalf. 
advance payments if you were an eligible trade          Box 2. Shows the total number of months you received 
adjustment assistance (TAA) recipient, an Alternative   HCTC payments.
TAA (ATAA) recipient, a Reemployment TAA (RTAA)         Boxes 3 through 14. Shows the amount of HCTC 
recipient, or a Pension Benefit Guaranty Corporation    advance payments paid for you for each month. The 
(PBGC) pension payee. See Form 8885, Health             total of the amounts shown in these boxes equals the 
Coverage Tax Credit, and its instructions for more      amount shown in box 1.
details on qualified recipients and how to figure any 
credit that you may be able to take on your Form 1040,  Future developments. For the latest information about 
1040-SR, 1040-NR, 1040-SS, or 1040-PR.                  developments related to Form 1099-H and its 
                                                        instructions, such as legislation enacted after they were 
Recipient’s taxpayer identification number (TIN). For   published, go to www.irs.gov/Form1099H. 
your protection, this form may show only the last four 
digits of your TIN (social security number (SSN),       Free File Program. Go to www.irs.gov/FreeFile to see if 
individual taxpayer identification number (ITIN), or    you qualify for no-cost online federal tax preparation, 
adoption taxpayer identification number (ATIN)).        e-filing, and direct deposit or payment options.

                                    VOID                         CORRECTED
ISSUER'S/PROVIDER'S name, street address, city or town, state or         1 Amount of HCTC advance OMB No. 1545-1813
province, country, ZIP or foreign postal code, and telephone no.          payments                 Form 1099-H           Health Coverage 
                                                                         $
                                                                         2 No. of mos. HCTC       (Rev. January 2022)    Tax Credit (HCTC) 
                                                                            payments received      For calendar year     Advance Payments
                                                                                                        20
ISSUER'S/PROVIDER'S TIN             RECIPIENT'S TIN                      3 Jan.                   9 July
                                                                         $                        $
RECIPIENT'S name                                                         4 Feb.                   10 Aug.                Copy C
                                                                         $                        $                      For 
                                                                         5 Mar.                   11 Sept.               Issuer/Provider
                                                                         $                        $                      For Privacy Act 
Street address (including apt. no.)                                      6 Apr.                   12 Oct.                and Paperwork 
                                                                         $                        $                      Reduction Act 
City or town, state or province, country, and ZIP or foreign postal code 7 May                    13 Nov.                Notice, see the 
                                                                                                                         current General 
                                                                         $                        $                      Instructions for 
                                                                         8 June                   14 Dec.                Certain Information 
                                                                         $                        $                      Returns.
Form  1099-H (Rev. 1-2022)                                                 www.irs.gov/Form1099H    Department of the Treasury - Internal Revenue Service

Instructions for Issuer/Provider                         Need help? If you have questions about reporting on 
To complete Form 1099-H, use:                            Form 1099-H, call the information reporting customer 
                                                         service site toll free at 866-455-7438 or 304-263-8700 
• The current General Instructions for Certain           (not toll free). Persons with a hearing or speech 
Information Returns, and                                 disability with access to TTY/TDD equipment can call 
• The current Instructions for Form 1099-H.              304-579-4827 (not toll free). 
To order these instructions and additional forms, go to 
www.irs.gov/EmployerForms.
Filing and furnishing. For filing and furnishing 
instructions, including due dates, and requesting filing 
or furnishing extensions, see the current General 
Instructions for Certain Information Returns.