9393                          VOID         CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1  Gross long-term care       OMB No. 1545-1519
or foreign postal code, and telephone no.                                     benefits paid
                                                                                                          Form 1099-LTC       Long-Term Care and 
                                                                                                          (Rev. October 2019)        Accelerated Death 
                                                                            $
                                                                                                                                                     Benefits
                                                                            2  Accelerated death benefits For calendar year
                                                                              paid                              20
PAYER’S TIN                         POLICYHOLDER’S TIN                      $                             INSURED’S TIN                              Copy A
                                                                            3  Check one:                                                            For 
                                                                              Per          Reimbursed 
POLICYHOLDER’S name                                                           diem         amount                                                    Internal Revenue 
                                                                                                                                                     Service Center
                                                                            INSURED’S name                                                           File with Form 1096. 
                                                                                                                                                     For Privacy Act 
Street address (including apt. no.)                                         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    City or town, state or province, country, and ZIP or foreign postal code current General 
                                                                                                                                                     Instructions for 
                                                                                                                                                     Certain 
Account number (see instructions)         4  Qualified contract             5  Check, if applicable   Chronically ill Date certified                 Information 
                                               (optional)                     (optional):             Terminally ill                                 Returns.
Form  1099-LTC (Rev. 10-2019)             Cat. No. 23021Z                   www.irs.gov/Form1099LTC       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)
PAYER’S name, street address, city or town, state or province, country, ZIP 1  Gross long-term care       OMB No. 1545-1519
or foreign postal code, and telephone no.                                     benefits paid
                                                                                                          Form 1099-LTC       Long-Term Care and 
                                                                                                          (Rev. October 2019)        Accelerated Death 
                                                                            $
                                                                                                                                                     Benefits
                                                                            2  Accelerated death benefits For calendar year
                                                                              paid                              20
PAYER’S TIN                         POLICYHOLDER’S TIN                      $                             INSURED’S TIN                              Copy B
                                                                            3                                                                        For Policyholder
                                                                              Per          Reimbursed 
POLICYHOLDER’S name                                                           diem         amount                                                    This is important tax 
                                                                                                                                                     information and is being 
                                                                            INSURED’S name                                                           furnished to the IRS. If 
                                                                                                                                                     you are required to file a 
                                                                                                                                                      return, a negligence 
Street address (including apt. no.)                                         Street address (including apt. no.)                                      penalty or other 
                                                                                                                                                     sanction may be 
City or town, state or province, country, and ZIP or foreign postal code    City or town, state or province, country, and ZIP or foreign postal code imposed on you if this 
                                                                                                                                                     item is required to be 
                                                                                                                                                     reported and the IRS 
Account number (see instructions)         4  Qualified contract             5  (optional)             Chronically ill Date certified                 determines that it has 
                                           (optional)                                                 Terminally ill                                 not been reported.
Form  1099-LTC (Rev. 10-2019)             (keep for your records)           www.irs.gov/Form1099LTC       Department of the Treasury - Internal Revenue Service

Instructions for Policyholder
A payer, such as an insurance company or a viatical settlement provider, must         individuals who are certified as chronically ill are excludable from income to the 
give this form to you for payments made under a long-term care insurance              same extent they would be if paid under a qualified long-term care insurance 
contract or for accelerated death benefits. Payments include those made               contract.
directly to you (or to the insured) and those made to third parties.                  Policyholder’s taxpayer identification number (TIN). For your protection, this 
A long-term care insurance contract provides coverage of expenses for long-           form may show only the last four digits of your TIN (social security number 
term care services for an individual who has been certified by a licensed health      (SSN), individual taxpayer identification number (ITIN), adoption taxpayer 
care practitioner as chronically ill. A life insurance company or viatical settlement identification number (ATIN), or employer identification number (EIN)). However, 
provider may pay accelerated death benefits if the insured has been certified         the issuer has reported your complete TIN to the IRS.
either by a physician as terminally ill or by a licensed health care practitioner as  Account number. May show an account or other unique number the payer 
chronically ill.                                                                      assigned to distinguish your account.
Long-term care insurance contract. Generally, amounts received under a                Box 1. Shows the gross benefits paid under a long-term care insurance contract 
qualified long-term care insurance contract are excluded from your income.            during the year.
However, if payments are made on a per diem basis, the amount you may                 Box 2. Shows the gross accelerated death benefits paid during the year.
exclude is limited. The per diem exclusion limit must be allocated among all          Box 3. Shows if the amount in box 1 or 2 was paid on a per diem basis or was 
policyholders who own qualified long-term care insurance contracts for the            reimbursement of actual long-term care expenses. If the insured was terminally 
same insured. See Pub. 525 and Form 8853 and its instructions for more                ill, this box may not be checked.
information.                                                                          Box 4. May show if the benefits were from a qualified long-term care insurance 
Per diem basis. This means the payments were made on any periodic basis               contract. 
without regard to the actual expenses incurred during the period to which the         Box 5. May show if the insured was certified chronically ill or terminally ill and 
payments relate.                                                                      the latest date certified.
Accelerated death benefits. Amounts paid as accelerated death benefits are            Future developments. For the latest developments related to Form 1099-LTC 
fully excludable from your income if the insured has been certified by a              and its instructions, such as legislation enacted after they were published, go to 
physician as terminally ill. Accelerated death benefits paid on behalf of             www.irs.gov/Form1099LTC. 

                                                       CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province, country, ZIP 1  Gross long-term care       OMB No. 1545-1519
or foreign postal code, and telephone no.                                     benefits paid
                                                                                                          Form 1099-LTC       Long-Term Care and 
                                                                                                          (Rev. October 2019)        Accelerated Death 
                                                                            $
                                                                                                                                                     Benefits
                                                                            2  Accelerated death benefits For calendar year
                                                                              paid                              20
PAYER’S TIN                         POLICYHOLDER’S TIN                      $                             INSURED’S TIN                              Copy C
                                                                            3                                                                        For Insured
                                                                              Per          Reimbursed 
POLICYHOLDER’S name                                                           diem         amount
                                                                            INSURED’S name                                                           Copy C is 
                                                                                                                                                     provided to you 
                                                                                                                                                     for information 
Street address (including apt. no.)                                         Street address (including apt. no.)                                      only. Only the 
                                                                                                                                                     policyholder is 
City or town, state or province, country, and ZIP or foreign postal code    City or town, state or province, country, and ZIP or foreign postal code required to 
                                                                                                                                                     report this 
                                                                                                                                                     information on 
Account number (see instructions)         4  Qualified contract             5  (optional)             Chronically ill Date certified                 a tax return.
                                           (optional)                                                 Terminally ill
Form  1099-LTC (Rev. 10-2019)             (keep for your records)           www.irs.gov/Form1099LTC       Department of the Treasury - Internal Revenue Service

Instructions for Insured
A payer, such as an insurance company or a viatical         Box 1. Shows the gross benefits paid under a long-term 
settlement provider, must give this form to you and to the  care insurance contract during the year.
policyholder for payments made under a long-term care       Box 2. Shows the gross accelerated death benefits paid 
insurance contract or for accelerated death benefits.       during the year.
Payments include both benefits you received directly and    Box 3. Shows if the amount in box 1 or 2 was paid on a 
expenses paid on your behalf to third parties.              per diem basis or was reimbursement of actual long-term 
If you are the insured but are not the policyholder, Copy   care expenses. If you are terminally ill this box may not be 
C is provided to you for information only because these     checked.
payments are not taxable to you. If you are also the        Box 4. May show if the benefits were from a qualified long-
policyholder, you should receive Copy B.                    term care insurance contract.
Insured’s taxpayer identification number (TIN). For your    Box 5. May show if you were certified chronically ill or 
protection, this form may show only the last four digits of terminally ill and the latest date certified.
your TIN (social security number (SSN), individual taxpayer Future developments. For the latest developments related 
identification number (ITIN), adoption taxpayer             to Form 1099-LTC 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 issuer has reported your        Form1099LTC. 
complete TIN to the IRS.
Account number. May show an account or other unique 
number the payer assigned to distinguish your account.

                                          VOID         CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1  Gross long-term care       OMB No. 1545-1519
or foreign postal code, and telephone no.                                     benefits paid
                                                                                                          Form 1099-LTC       Long-Term Care and 
                                                                                                          (Rev. October 2019)        Accelerated Death 
                                                                            $
                                                                                                                                                     Benefits
                                                                            2  Accelerated death benefits For calendar year
                                                                              paid                              20
PAYER’S TIN                         POLICYHOLDER’S TIN                      $                             INSURED’S TIN                              Copy D
                                                                            3                                                                        For Payer
                                                                              Per          Reimbursed 
POLICYHOLDER’S name                                                           diem         amount
                                                                            INSURED’S name                                                           For Privacy Act 
                                                                                                                                                     and Paperwork 
                                                                                                                                                     Reduction Act 
Street address (including apt. no.)                                         Street address (including apt. no.)                                      Notice, see the 
                                                                                                                                                     current General 
City or town, state or province, country, and ZIP or foreign postal code    City or town, state or province, country, and ZIP or foreign postal code Instructions for 
                                                                                                                                                     Certain 
                                                                                                                                                     Information 
Account number (see instructions)         4  Qualified contract             5  Check, if applicable   Chronically ill Date certified                 Returns.
                                               (optional)                     (optional):             Terminally ill
Form  1099-LTC (Rev. 10-2019)                  www.irs.gov/Form1099LTC                                    Department of the Treasury - Internal Revenue Service

Instructions for Payer
To complete Form 1099-LTC, 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. 
Information Returns, and
• The current Instructions for Form 1099-LTC.               Need help? If you have questions about reporting on 
                                                            Form 1099-LTC, call the information reporting customer 
To get or to order these instructions, go to                service site toll free at 866-455-7438 or 304-263-8700 
www.irs.gov/Form1099LTC.                                    (not toll free). Persons with a hearing or speech 
Filing and furnishing. For filing and furnishing            disability with access to TTY/TDD equipment can call 
instructions, including due dates, and to request filing or 304-579-4827 (not toll free). 
furnishing extensions, see the current General 
Instructions for Certain Information Returns.