Form 1099-H - Health Coverage Tax Credit (Hctc) Advance Payments - 2012 Page 2
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87171
VOID
CORRECTED
ISSUER'S/PROVIDER'S name, street address, city, state, ZIP code, and
1 Amount of HCTC advance
OMB No. 1545-1813
payments
Health Coverage
telephone no.
$
2012
Tax Credit (HCTC)
2 No. of mos. HCTC
payments received
Advance Payments
1099-H
Form
Copy A
3 Jan.
9 July
ISSUER'S/PROVIDER'S federal identification number
RECIPIENT'S identification number
For
$
$
Internal Revenue
RECIPIENT'S name
4 Feb.
10 Aug.
Service Center
$
$
5 Mar.
11 Sept.
File with Form 1096.
$
$
For Privacy Act
and Paperwork
Street address (including apt. no.)
6 Apr.
12 Oct.
Reduction Act
$
$
Notice, see the
7 May
13 Nov.
City, state, and ZIP code
2012 General
$
$
Instructions for
Certain Information
8 June
14 Dec.
Returns.
$
$
1099-H
Form
Cat. No. 34912D
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
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