Form 1099-Ltc - Long Term Care And Accelerated Death Benefits - 2018
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79393
VOID
CORRECTED
PAYER'S name, street address, city or town, state or province, country, ZIP
1 Gross long-term care
OMB No. 1545-1519
benefits paid
or foreign postal code, and telephone no.
Long-Term Care and
2018
Accelerated Death
$
Benefits
2 Accelerated death benefits
paid
1099-LTC
Form
Copy A
$
PAYER’S TIN
POLICYHOLDER'S TIN
INSURED'S TIN
For
3 Check one:
Internal Revenue
Per
Reimbursed
POLICYHOLDER'S name
diem
amount
Service Center
INSURED'S name
File with Form 1096.
For Privacy Act
and Paperwork
Street address (including apt. no.)
Street address (including apt. no.)
Reduction Act
Notice, see the
2018 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
Account number (see instructions)
4 Qualified contract
5 Check, if applicable:
Date certified
Chronically ill
Information
(optional)
(optional)
Returns.
Terminally ill
1099-LTC
Form
Cat. No. 23021Z
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
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