0425 Form 1099-H (PDF) — verbatim text

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f1099h.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

General Instructions for Certain Information

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For Internal Revenue

Service Center

For filing information,

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Reduction Act Notice, see the

Returns . www.irs.gov/Form1099

9090 VOID CORREC		CTED
ISSUER’S/PROVIDER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	ISSUER’S/PROVIDER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	1 Amount of HCTC advance payments $	Form1099-H (Rev. April 2025) OMB No. 1545-1813
ISSUER’S/PROVIDER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	ISSUER’S/PROVIDER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	2 No. of mos. HCTC payments received	2 No. of mos. HCTC payments received
ISSUER’S/PROVIDER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	ISSUER’S/PROVIDER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	2 No. of mos. HCTC payments received	For calendar year
ISSUER’S/PROVIDER’S TIN	RECIPIENT’S TIN	3 Jan. $	9 July $
RECIPIENT’S name	RECIPIENT’S name	4 Feb. $	10 Aug. $
RECIPIENT’S name	RECIPIENT’S name	5 Mar. $	11 Sept. $
Street address (including apt. no.)	Street address (including apt. no.)	6 Apr. $	12 Oct. $
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	7 May $	13 Nov. $
		8 June $	14 Dec. $

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Cat. No. 34912D

Department of the Treasury - Internal Revenue Service

CORRECTED (if checked)

Copy B

For Recipient

This is important

tax information

and is being furnished to the

IRS.

ISSUER’S/PROVIDER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.		1 Amount of HCTC advance payments $	OMB No. 1545-1813 1099-H Form (Rev. April 2025)
ISSUER’S/PROVIDER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	ISSUER’S/PROVIDER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	2 No. of mos. of HCTC advance payments and reimbursement credits paid to you	2 No. of mos. of HCTC advance payments and reimbursement credits paid to you
ISSUER’S/PROVIDER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	ISSUER’S/PROVIDER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	2 No. of mos. of HCTC advance payments and reimbursement credits paid to you	For calendar year
ISSUER’S/PROVIDER’S TIN	RECIPIENT’S TIN	3 Jan. $	9 July $
RECIPIENT’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	RECIPIENT’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	4 Feb. $	10 Aug. $
RECIPIENT’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	RECIPIENT’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	5 Mar. $	11 Sept. $
RECIPIENT’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	RECIPIENT’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	6 Apr. $	12 Oct. $
RECIPIENT’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	RECIPIENT’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	7 May $	13 Nov. $
		8 June $	14 Dec. $

Department of the Treasury - Internal Revenue Service

Instructions for Recipient This statement is provided to you because you received Health Coverage Tax Credit (HCTC) advance payments of your health coverage insurance premiums. These advance payments were forwarded directly to your health insurance provider. You are qualified to receive advance payments if you were an eligible trade adjustment assistance (TAA) recipient, an Alternative TAA (ATAA) recipient, a Reemployment TAA (RTAA) recipient, or a Pension Benefit Guaranty Corporation (PBGC) pension payee. See Form 8885, Health Coverage Tax Credit, and its instructions for more details on qualified recipients and how to figure any credit that you may be able to take on your Form 1040, 1040-SR, 1040-NR, 1040-SS, or 1040-PR. Recipient’s taxpayer identification number (TIN). For your protection, this form may show only the last four digits of your TIN (social security number (SSN), individual taxpayer identification number (ITIN), or adoption taxpayer identification number (ATIN)).

However, the issuer has reported your complete TIN to the IRS. Box 1. Shows the total amount of HCTC advance payments of qualified health insurance costs that were made on your behalf. Box 2. Shows the total number of months you received HCTC payments. Boxes 3 through 14. Shows the amount of HCTC advance payments paid for you for each month. The total of the amounts shown in these boxes equals the amount shown in box 1. Future developments. For the latest information about developments related to Form 1099-H and its instructions, such as legislation enacted after they were published, go to www.irs.gov/Form1099H . Free File Program. Go to www.irs.gov/FreeFile to see if you qualify for no-cost online federal tax preparation, e-filing, and direct deposit or payment options.