Form 1099-H - Health Coverage Tax Credit (Hctc) Advance Payments - 2013 Page 5
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8CORRECTED (if checked)
ISSUER'S/PROVIDER'S name, street address, city or town, province or state,
1
OMB No. 1545-1813
Amt. of HCTC advance payments and
reimbursement credits paid to you
Health Coverage
country, ZIP or foreign postal code, and telephone no.
$
2013
Tax Credit (HCTC)
2
No. of mos. HCTC advance payments
and reimbursement credits paid to you
Advance Payments
1099-H
Form
3 Jan.
9 July
ISSUER'S/PROVIDER'S federal identification number
RECIPIENT'S identification number
$
$
Copy 1
RECIPIENT'S name
4 Feb.
10 Aug.
For Recipient
$
$
(Issued by the
5 Mar.
11 Sept.
HCTC Program)
$
$
Street address (including apt. no.)
6 Apr.
12 Oct.
This is important
$
$
tax information
7 May
13 Nov.
City or town, province or state, country, and ZIP or foreign postal code
and is being
furnished to the
$
$
Internal Revenue
8 June
14 Dec.
Service.
$
$
1099-H
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service
DO NOT FILE THIS FORM WITH YOUR FEDERAL INCOME TAX RETURN. THIS FORM IS FOR YOUR INFORMATION ONLY.
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