Form 1099-Ltc - Long-Term Care And Accelerated Death Benefits - Department Of The Treasury - 2013 Page 2

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9393
VOID
CORRECTED
PAYER'S name, street address, city or town, province or state, country, ZIP
1 Gross long-term care
OMB No. 1545-1519
benefits paid
or foreign postal code, and telephone no.
Long-Term Care and
$
2013
Accelerated Death
2 Accelerated death
Benefits
benefits paid
1099-LTC
$
Form
Copy A
PAYER’S federal identification number
POLICYHOLDER'S identification number
3 Check one:
INSURED'S social security no.
Per
Reimbursed
For
diem
amount
Internal Revenue
POLICYHOLDER'S name
INSURED'S name
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Street address (including apt. no.)
Street address (including apt. no.)
Reduction Act
Notice, see the
2013 General
City or town, province or state, country, and ZIP or foreign postal code
City or town, province or state, country, and ZIP or foreign postal code
Instructions for
Certain
Account number (see instructions)
4 Qualified contract
5 Check, if applicable:
Date certified
Chronically ill
Information
(optional)
(optional)
Returns.
Terminally ill
1099-LTC
Form
Cat. No. 23021Z
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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