Form 1099-H - Health Coverage Tax Credit (Hctc) Advance Payments - 2018 Page 4
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5VOID
CORRECTED
ISSUER'S/PROVIDER'S name, street address, city or town, state or province,
1 Amount of HCTC advance
OMB No. 1545-1813
payments
Health Coverage
country, ZIP or foreign postal code, and telephone no.
$
2018
Tax Credit (HCTC)
2 No. of mos. HCTC
payments received
Advance Payments
1099-H
Form
3 Jan.
9 July
ISSUER'S/PROVIDER'S TIN
RECIPIENT'S TIN
$
$
Copy C
RECIPIENT'S name
4 Feb.
10 Aug.
For
$
$
Issuer/Provider
5 Mar.
11 Sept.
For Privacy Act
$
$
and Paperwork
Reduction Act
Street address (including apt. no.)
6 Apr.
12 Oct.
Notice, see the
$
$
2018 General
7 May
13 Nov.
City or town, state or province, country, and ZIP or foreign postal code
Instructions for
$
$
Certain Information
Returns.
8 June
14 Dec.
$
$
1099-H
Form
Department of the Treasury - Internal Revenue Service
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