Form 1099-Ltc - Long-Term Care And Accelerated Death Benefits - 2016

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CORRECTED (if checked)
1 Gross long-term care
PAYER'S name, street address, city or town, state or province, country, ZIP
OMB No. 1545-1519
or foreign postal code, and telephone no.
benefits paid
Long-Term Care and
2016
Accelerated Death
$
Benefits
2 Accelerated death benefits
paid
1099-LTC
Form
Copy B
$
PAYER’S federal identification number POLICYHOLDER'S identification number
INSURED'S taxpayer identification no.
For Policyholder
3
Per
Reimbursed
This is important tax
POLICYHOLDER'S name, street address, city or town, state or province, country, and ZIP or foreign postal code
diem
amount
information and is being
INSURED'S name, street address, city or town, state or province, country, and ZIP or foreign postal code
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
4 Qualified contract
5 (optional)
Account number (see instructions)
Chronically ill
Date certified
determines that it has
(optional)
Terminally ill
not been reported.
1099-LTC
(keep for your records)
Department of the Treasury - Internal Revenue Service
Form
CORRECTED (if checked)
1 Gross long-term care
PAYER'S name, street address, city or town, state or province, country, ZIP
OMB No. 1545-1519
benefits paid
or foreign postal code, and telephone no.
Long-Term Care and
2016
Accelerated Death
$
Benefits
2 Accelerated death benefits
paid
1099-LTC
Form
Copy B
$
PAYER’S federal identification number POLICYHOLDER'S identification number
INSURED'S taxpayer identification no.
For Policyholder
3
Per
Reimbursed
This is important tax
POLICYHOLDER'S name, street address, city or town, state or province, country, and ZIP or foreign postal code
diem
amount
information and is being
INSURED'S name, street address, city or town, state or province, country, and ZIP or foreign postal code
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
4 Qualified contract
5 (optional)
Account number (see instructions)
Date certified
Chronically ill
determines that it has
(optional)
Terminally ill
not been reported.
1099-LTC
(keep for your records)
Department of the Treasury - Internal Revenue Service
Form
CORRECTED (if checked)
1 Gross long-term care
PAYER'S name, street address, city or town, state or province, country, ZIP
OMB No. 1545-1519
benefits paid
or foreign postal code, and telephone no.
Long-Term Care and
2016
Accelerated Death
$
Benefits
2 Accelerated death benefits
paid
1099-LTC
Form
Copy B
$
PAYER’S federal identification number POLICYHOLDER'S identification number
INSURED'S taxpayer identification no.
For Policyholder
3
Per
Reimbursed
This is important tax
POLICYHOLDER'S name, street address, city or town, state or province, country, and ZIP or foreign postal code
diem
amount
information and is being
INSURED'S name, street address, city or town, state or province, country, and ZIP or foreign postal code
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
4 Qualified contract
5 (optional)
Account number (see instructions)
Chronically ill
Date certified
determines that it has
(optional)
Terminally ill
not been reported.
1099-LTC
(keep for your records)
Department of the Treasury - Internal Revenue Service
LLTCB
5191
Form

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