Form 1099-Ltc - Long-Term Care And Accelerated Death Benefits - 2016 Page 2
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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
2016
Accelerated Death
$
Benefits
2 Accelerated death benefits
paid
1099-LTC
Form
$
Copy B
PAYER’S federal identification number POLICYHOLDER'S identification number
INSURED'S taxpayer identification no.
For Policyholder
3
Per
Reimbursed
This is important tax
POLICYHOLDER'S name
diem
amount
information and is being
INSURED'S name
furnished to the Internal
Revenue Service. If you
are required to file a
Street address (including apt. no.)
Street address (including apt. no.)
return, a negligence
penalty or other
sanction may be
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
imposed on you if this
item is required to be
reported and the IRS
Account number (see instructions)
4 Qualified contract
5 (optional)
Date certified
Chronically ill
determines that it has
(optional)
Terminally ill
not been reported.
1099-LTC
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service
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