Form 1099-Ltc - Long Term Care And Accelerated Death Benefits - 2018 Page 2
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7CORRECTED (if checked)
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 B
PAYER’S TIN
POLICYHOLDER'S TIN
INSURED'S TIN
For Policyholder
3
Per
Reimbursed
This is important tax
POLICYHOLDER'S name
diem
amount
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
imposed on you if this
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
item is required to be
reported and the IRS
determines that it has
Account number (see instructions)
4 Qualified contract
5 (optional)
Date certified
Chronically ill
not been reported.
(optional)
Terminally ill
1099-LTC
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service
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