Form 1099-Ltc - Long Term Care And Accelerated Death Benefits - 2018 Page 6
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7VOID
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
$
PAYER’S TIN
POLICYHOLDER'S TIN
INSURED'S TIN
Copy D
3
For Payer
Per
Reimbursed
POLICYHOLDER'S name
diem
amount
For Privacy Act
INSURED'S name
and Paperwork
Reduction Act
Street address (including apt. no.)
Street address (including apt. no.)
Notice, see the
2018 General
Instructions for
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
Certain
Information
Account number (see instructions)
4 Qualified contract
5 Check, if applicable:
Date certified
Chronically ill
Returns.
(optional)
(optional)
Terminally ill
1099-LTC
Form
Department of the Treasury - Internal Revenue Service
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