Form 1099-Ltc - Long Term Care And Accelerated Death Benefits - 2017 Page 4
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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
2017
Accelerated Death
$
Benefits
2 Accelerated death benefits
paid
1099-LTC
Form
$
Copy C
PAYER’S federal identification number POLICYHOLDER'S identification number
INSURED'S taxpayer identification no.
For Insured
3
Per
Reimbursed
POLICYHOLDER'S name
diem
amount
Copy C is
INSURED'S name
provided to you
for information
Street address (including apt. no.)
Street address (including apt. no.)
only. Only the
policyholder is
required to
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
report this
information on
Account number (see instructions)
4 Qualified contract
5 (optional)
Date certified
Chronically ill
a tax return.
(optional)
Terminally ill
1099-LTC
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service
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Parent category: Financial