Form 1099-H - Health Coverage Tax Credit (Hctc) Advance Payments - 2012 Page 3
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8CORRECTED (if checked)
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
3 Jan.
9 July
ISSUER'S/PROVIDER'S federal identification number
RECIPIENT'S identification number
$
$
Copy B
RECIPIENT'S name
4 Feb.
10 Aug.
$
$
For Recipient
5 Mar.
11 Sept.
This is important
$
$
tax information
Street address (including apt. no.)
6 Apr.
12 Oct.
and is being
$
$
furnished to the
Internal Revenue
7 May
13 Nov.
City, state, and ZIP code
Service.
$
$
8 June
14 Dec.
$
$
1099-H
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service
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