Attention: 

Copy A of this form is provided for informational purposes only. Copy A appears in red, 
similar to the official IRS form. The official printed version of Copy A of this IRS form is 
scannable, but the online version of it, printed from this website, is not. Do not print and file 
copy A downloaded from this website; a penalty may be imposed for filing with the IRS 
information return forms that can’t be scanned. See part O in the current General 
Instructions for Certain Information Returns, available at www.irs.gov/form1099, for more 
information about penalties.

Please note that Copy B and other copies of this form, which appear in black, may be 
downloaded and printed and used to satisfy the requirement to provide the information to 
the recipient.

To order official IRS information returns, which include a scannable Copy A for filing with 
the IRS and all other applicable copies of the form, visit www.IRS.gov/orderforms. Click on 
Employer and Information Returns, and we’ll mail you the forms you request and their 
instructions, as well as any publications you may order.

Information returns may also be filed electronically using the IRS Filing Information Returns 
Electronically (FIRE) system (visit www.IRS.gov/FIRE) or the IRS Affordable Care Act 
Information Returns (AIR) program (visit www.IRS.gov/AIR).

See IRS Publications 1141, 1167, and 1179 for more information about printing these tax 
forms.

                    1616                      VOID            CORRECTED
ACQUIRER’S name, street address, city or town, state or province, country, 1  Amount paid to payment OMB No. 1545-2281
ZIP or foreign postal code, and telephone no.                                recipient
                                                                           $                         Form 1099-LS                        Reportable Life 
                                                                           2  Date of sale           (Rev. December 2019)                Insurance Sale
                                                                                                     For calendar year     
                                                                                                          20
ACQUIRER’S TIN                      PAYMENT RECIPIENT’S TIN                Issuer’s name                                                 Copy A
                                                                                                                                                 For 
PAYMENT RECIPIENT’S name                                                   Acquirer’s information contact name, street address, city or  Internal Revenue 
                                                                           town, state or province, country, ZIP or foreign postal code, Service Center
                                                                           and telephone no. (if different from ACQUIRER)                File with Form 1096. 
                                                                                                                                         For Privacy Act 
Street address (including apt. no.)                                                                                                      and Paperwork 
                                                                                                                                         Reduction Act 
                                                                                                                                         Notice, see the 
City or town, state or province, country, and ZIP or foreign postal code                                                                 current General 
                                                                                                                                         Instructions for 
                                                                                                                                                 Certain 
Policy number                                                                                                                            Information 
                                                                                                                                         Returns.
Form 1099-LS (Rev. 12-2019)                   Cat. No. 71383M              www.irs.gov/Form1099LS    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)
ACQUIRER’S name, street address, city or town, state or province, country, 1  Amount paid to payment OMB No. 1545-2281
ZIP or foreign postal code, and telephone no.                                recipient
                                                                           $                         Form 1099-LS                        Reportable Life 
                                                                           2  Date of sale           (Rev. December 2019)                Insurance Sale
                                                                                                     For calendar year     
                                                                                                          20
ACQUIRER’S TIN                      PAYMENT RECIPIENT’S TIN                Issuer’s name                                                 Copy B
                                                                                                                                         For Payment 
PAYMENT RECIPIENT’S name                                                   Acquirer’s information contact name, street address, city or  Recipient
                                                                           town, state or province, country, ZIP or foreign postal code, This is important tax 
                                                                           and telephone no. (if different from ACQUIRER)                information and is being 
                                                                                                                                         furnished to the IRS. If 
Street address (including apt. no.)                                                                                                      you are required to file a 
                                                                                                                                          return, a negligence 
                                                                                                                                         penalty or other 
City or town, state or province, country, and ZIP or foreign postal code                                                                 sanction may be 
                                                                                                                                         imposed on you if this 
                                                                                                                                         item is required to be 
Policy number                                                                                                                            reported and the IRS 
                                                                                                                                         determines that it has 
                                                                                                                                         not been reported.
Form 1099-LS (Rev. 12-2019)         (keep for your records)                www.irs.gov/Form1099LS    Department of the Treasury - Internal Revenue Service

Instructions for Payment Recipient
An acquirer of a life insurance contract or any interest in a life Box 2. Shows the date of sale.
insurance contract in a reportable policy sale under section       Issuer’s name. Shows the insurance company that bears the 
6050Y must give this form to you for payments made to you in       risk with respect to the life insurance contract on the date a 
the reportable policy sale.                                        Form 1099-LS is required to be furnished to that issuer. 
Payment recipient’s taxpayer identification number (TIN).          Generally, this will be the life insurance company responsible 
For your protection, this form may show only the last four         for administering the contract, including paying death benefits 
digits of your TIN (social security number (SSN), individual       under the life insurance contract.
taxpayer identification number (ITIN), adoption taxpayer           Acquirer’s information contact name, address, and phone 
identification number (ATIN), or employer identification number    number. Shows the contact information of the acquirer. The 
(EIN)). However, the acquirer has reported your complete TIN       contact information provided will give you direct access to a 
to the IRS.                                                        person who can answer questions about this form. If blank, 
Policy number. Shows the policy number the life insurance          the contact information is the same as the ACQUIRER.
company assigned to the life insurance contract.                   Future developments. For the latest developments related to 
Box 1. Shows the amount paid to you in the reportable policy       Form 1099-LS and its instructions, such as legislation enacted 
sale under section 6050Y.                                          after they were published, go to www.irs.gov/Form1099LS. 

                                              CORRECTED (if checked)
ACQUIRER’S name, street address, city or town, state or province, country, 1  Amount paid to payment OMB No. 1545-2281
ZIP or foreign postal code, and telephone no.                                recipient (optional)
                                                                           $                         Form 1099-LS                        Reportable Life 
                                                                           2  Date of sale           (Rev. December 2019)                Insurance Sale
                                                                                                     For calendar year     
                                                                                                          20
ACQUIRER’S TIN                      PAYMENT RECIPIENT’S TIN                Issuer’s name                                                 Copy C
                                                                                                                                         For Issuer
PAYMENT RECIPIENT’S name                                                   Acquirer’s information contact name, street address, city or 
                                                                           town, state or province, country, ZIP or foreign postal code, Copy C is 
                                                                           and telephone no. (if different from ACQUIRER)                provided to you 
                                                                                                                                         for information 
Street address (including apt. no.)                                                                                                      only. Only the 
                                                                                                                                         payment recipient is 
City or town, state or province, country, and ZIP or foreign postal code                                                                 required to 
                                                                                                                                         report this 
                                                                                                                                         information on 
Policy number                                                                                                                            a tax return.

Form 1099-LS (Rev. 12-2019)         (keep for your records)                www.irs.gov/Form1099LS    Department of the Treasury - Internal Revenue Service

Instructions for Issuer
An acquirer of a life insurance contract or any interest in a Box 1. This box may show the amount paid to the payment 
life insurance contract in a reportable policy sale under     recipient.
section 6050Y must give this form to you to report the        Box 2. Shows the date of sale.
acquisition.                                                  Issuer’s name. Shows your name as the insurance 
If you are the issuer, Copy C is provided to you because      company that bears the risk with respect to the life 
you have an information reporting obligation under section    insurance contract on the date a Form 1099-LS is required 
6050Y(b). You must file a Form 1099-SB with respect to        to be furnished to you.
the reportable policy sale under section 6050Y.               Acquirer’s information contact name, address, and 
Payment recipient’s taxpayer identification number            phone number. Shows the contact information of the 
(TIN). For the payment recipient’s protection, this form may  acquirer. If blank, the information is the same as 
show only the last four digits of the payment recipient’s     ACQUIRER.
TIN (social security number (SSN), individual taxpayer        Future developments. For the latest developments related 
identification number (ITIN), adoption taxpayer               to Form 1099-LS and its instructions, such as legislation 
identification number (ATIN), or employer identification      enacted after they were published, go to www.irs.gov/
number (EIN)). However, the acquirer has reported the         Form1099LS. 
payment recipient’s complete TIN to the IRS.
Policy number. Shows the policy number assigned to the 
life insurance contract acquired from the payment 
recipient.

                                              VOID CORRECTED
ACQUIRER’S name, street address, city or town, state or province, country, 1  Amount paid to payment OMB No. 1545-2281
ZIP or foreign postal code, and telephone no.                                recipient
                                                                           $                         Form 1099-LS                        Reportable Life 
                                                                           2  Date of sale           (Rev. December 2019)                Insurance Sale
                                                                                                     For calendar year     
                                                                                                          20
ACQUIRER’S TIN                      PAYMENT RECIPIENT’S TIN                Issuer’s name                                                 Copy D
                                                                                                                                         For Acquirer
PAYMENT RECIPIENT’S name                                                   Acquirer’s information contact name, street address, city or 
                                                                           town, state or province, country, ZIP or foreign postal code, For Privacy Act 
                                                                           and telephone no. (if different from ACQUIRER)                and Paperwork 
                                                                                                                                         Reduction Act 
Street address (including apt. no.)                                                                                                      Notice, see the 
                                                                                                                                         current General 
City or town, state or province, country, and ZIP or foreign postal code                                                                 Instructions for 
                                                                                                                                         Certain 
                                                                                                                                         Information 
Policy number                                                                                                                            Returns.

Form 1099-LS (Rev. 12-2019)                        www.irs.gov/Form1099LS                            Department of the Treasury - Internal Revenue Service

Instructions for Acquirer
To complete Form 1099-LS, use:                              To file electronically, you must have software that 
                                                            generates a file according to the specifications in Pub. 
• The current General Instructions for Certain 
                                                            1220. The IRS does not provide a fill-in form option for 
Information Returns, and
                                                            Copy A.
• The current Instructions for Form 1099-LS.
                                                            Need help? If you have questions about reporting on 
To get or to order these instructions, go to                Form 1099-LS, call the information reporting customer 
www.irs.gov/Form1099LS.                                     service site toll free at 866-455-7438 or 304-263-8700 
Filing and furnishing. For filing and furnishing            (not toll free). Persons with a hearing or speech 
instructions, including due dates, and to request filing or disability with access to TTY/TDD equipment can call 
furnishing extensions, see the current General              304-579-4827 (not toll free). 
Instructions for Certain Information Returns.