0425 Form 1099-LTC (PDF) — verbatim text

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f1099ltc.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

Copy A

Benefits

For Internal Revenue

For filing information,

Privacy Act, and Paperwork Reduction

Act Notice, see the General Instructions

for Certain Information Returns .

www.irs.gov/Form1099

Service Center

9393 VOID CORREC			CTED
PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	1 Gross long-term care benefits paid $	Form1099-LTC (Rev. April 2025) OMB No. 1545-1519	Form1099-LTC (Rev. April 2025) OMB No. 1545-1519
PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	2 Accelerated death benefits paid $	For calendar year	For calendar year
PAYER’S TIN	POLICYHOLDER’S TIN	POLICYHOLDER’S TIN	POLICYHOLDER’S TIN	INSURED’S TIN	INSURED’S TIN
PAYER’S TIN	POLICYHOLDER’S TIN	POLICYHOLDER’S TIN	3 Check one: Per diem Reimbursed amount	3 Check one: Per diem Reimbursed amount	3 Check one: Per diem Reimbursed amount
POLICYHOLDER’S name	POLICYHOLDER’S name	POLICYHOLDER’S name	POLICYHOLDER’S name	POLICYHOLDER’S name	POLICYHOLDER’S name
POLICYHOLDER’S name	POLICYHOLDER’S name	POLICYHOLDER’S name	INSURED’S name	INSURED’S name	INSURED’S name
Street address (including apt. no.)	Street address (including apt. no.)	Street address (including apt. no.)	Street address (including apt. no.)	Street address (including apt. no.)	Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)	Account number (see instructions)	4 Qualified contract (optional)	5 Check, if applicable (optional): Chronically ill Terminally ill	5 Check, if applicable (optional): Chronically ill Terminally ill	Date certified

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

Cat. No. 23021Z

Department of the Treasury - Internal Revenue Service

CORRECTED (if checked)

Benefits

Copy B For Policyholder

This is important tax information and is being

furnished to the IRS. If you are required to file a

return, a negligence

penalty or other sanction may be imposed on you if this

item is required to be

reported and the IRS determines that it has

not been reported.

PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.			1 Gross long-term care benefits paid $	OMB No. 1545-1519 1099-LTC Form (Rev. April 2025)
PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	2 Accelerated death benefits paid $	For calendar year	For calendar year
PAYER’S TIN	POLICYHOLDER’S TIN	POLICYHOLDER’S TIN	POLICYHOLDER’S TIN	INSURED’S TIN	INSURED’S TIN
PAYER’S TIN	POLICYHOLDER’S TIN	POLICYHOLDER’S TIN	3 Per diem Reimbursed amount	3 Per diem Reimbursed amount	3 Per diem Reimbursed amount
POLICYHOLDER’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code
POLICYHOLDER’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	POLICYHOLDER’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	POLICYHOLDER’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	INSURED’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	INSURED’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	INSURED’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)	Account number (see instructions)	4 Qualified contract (optional)	5 (optional) Chronically ill Terminally ill	5 (optional) Chronically ill Terminally ill	Date certified

Department of the Treasury - Internal Revenue Service

Instructions for Policyholder A payer, such as an insurance company or a viatical settlement provider, must give this form to you for payments made under a long-term care insurance contract or for accelerated death benefits. Payments include those made directly to you (or to the insured) and those made to third parties.

A long-term care insurance contract provides coverage of expenses for longterm care services for an individual who has been certified by a licensed health care practitioner as chronically ill. A life insurance company or viatical settlement provider may pay accelerated death benefits if the insured has been certified either by a physician as terminally ill or by a licensed health care practitioner as chronically ill. Long-term care insurance contract. Generally, amounts received under a qualified long-term care insurance contract are excluded from your income. However, if payments are made on a per diem basis, the amount you may exclude is limited. The per diem exclusion limit must be allocated among all policyholders who own qualified long-term care insurance contracts for the same insured. See Pub. 525 and Form 8853 and its instructions for more information. Per diem basis. This means the payments were made on any periodic basis without regard to the actual expenses incurred during the period to which the payments relate. Accelerated death benefits. Amounts paid as accelerated death benefits are fully excludable from your income if the insured has been certified by a physician as terminally ill. Accelerated death benefits paid on behalf of

individuals who are certified as chronically ill are excludable from income to the same extent they would be if paid under a qualified long-term care insurance contract. Policyholder’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), adoption taxpayer identification number (ATIN), or employer identification number (EIN)). However, the issuer has reported your complete TIN to the IRS. Account number. May show an account or other unique number the payer assigned to distinguish your account. Box 1. Shows the gross benefits paid under a long-term care insurance contract during the year. Box 2. Shows the gross accelerated death benefits paid during the year. Box 3. Shows if the amount in box 1 or 2 was paid on a per diem basis or was reimbursement of actual long-term care expenses. If the insured was terminally ill, this box may not be checked. Box 4. May show if the benefits were from a qualified long-term care insurance contract. Box 5. May show if the insured was certified chronically ill or terminally ill and the latest date certified. Future developments. For the latest developments related to Form 1099-LTC and its instructions, such as legislation enacted after they were published, go to www.irs.gov/Form1099LTC .

CORRECTED (if checked)

Benefits

Copy C For Insured

Copy C is provided to you

for information

only. Only the policyholder is

required to

report this information on

a tax return.

PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.			1 Gross long-term care benefits paid $	OMB No. 1545-1519 1099-LTC Form (Rev. April 2025)
PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.	2 Accelerated death benefits paid $	For calendar year	For calendar year
PAYER’S TIN	POLICYHOLDER’S TIN	POLICYHOLDER’S TIN	POLICYHOLDER’S TIN	INSURED’S TIN	INSURED’S TIN
PAYER’S TIN	POLICYHOLDER’S TIN	POLICYHOLDER’S TIN	3 Per diem Reimbursed amount	3 Per diem Reimbursed amount	3 Per diem Reimbursed amount
POLICYHOLDER’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code
POLICYHOLDER’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	POLICYHOLDER’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	POLICYHOLDER’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	INSURED’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	INSURED’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code	INSURED’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)	Account number (see instructions)	4 Qualified contract (optional)	5 (optional) Chronically ill Terminally ill	5 (optional) Chronically ill Terminally ill	Date certified

Department of the Treasury - Internal Revenue Service

Instructions for Insured A payer, such as an insurance company or a viatical settlement provider, must give this form to you and to the policyholder for payments made under a long-term care insurance contract or for accelerated death benefits. Payments include both benefits you received directly and expenses paid on your behalf to third parties.

If you are the insured but are not the policyholder, Copy C is provided to you for information only because these payments are not taxable to you. If you are also the policyholder, you should receive Copy B. Insured’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), adoption taxpayer identification number (ATIN), or employer identification number (EIN)). However, the issuer has reported your complete TIN to the IRS. Account number. May show an account or other unique number the payer assigned to distinguish your account.

Box 1. Shows the gross benefits paid under a long-term care insurance contract during the year. Box 2. Shows the gross accelerated death benefits paid during the year. Box 3. Shows if the amount in box 1 or 2 was paid on a per diem basis or was reimbursement of actual long-term care expenses. If you are terminally ill, this box may not be checked. Box 4. May show if the benefits were from a qualified longterm care insurance contract. Box 5. May show if you were certified chronically ill or terminally ill and the latest date certified. Future developments. For the latest developments related to Form 1099-LTC and its instructions, such as legislation enacted after they were published, go to www.irs.gov/ Form1099LTC . 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.