Exhibit K
Internal Revenue Bulletin 2003-16 · 2026-10-03 edition · updated 2026-10-04 · United States
Health
Payments
Copy A
For Internal Revenue
Service Center File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act Notice, see the
2003 General Instructions for Forms 1099, 1098,
5498, and W-2G.
| PROVIDER’S name, street address, city, state, ZIP code, and telephone no. | 1Gross amount of health insurance advance payments $ |
OMB No. 1545-XXXX 2003 Form 1099-H |
|
|---|---|---|---|
| PROVIDER’S name, street address, city, state, ZIP code, and telephone no. |
PROVIDER’S name, street address, city, state, ZIP code, and telephone no. |
No. of months eligible 2 |
No. of months eligible 2 |
| PROVIDER’S name, street address, city, state, ZIP code, and telephone no. |
PROVIDER’S name, street address, city, state, ZIP code, and telephone no. |
Amount of advance payment(s) included in box 1 | Amount of advance payment(s) included in box 1 |
| PROVIDER’S Federal identification number | RECIPIENT’S identification number | Jan. $ 3 |
July $ 9 |
| RECIPIENT’S name | RECIPIENT’S name | Feb. $ 4 |
Aug. $ 10 |
| RECIPIENT’S name | RECIPIENT’S name | Mar. $ 5 |
Sept. $ 11 |
| 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.) | Apr. $ 6 |
Oct. $ 12 |
| City, state, and ZIP code | City, state, and ZIP code | City, state, and ZIP code | City, state, and ZIP code |
| City, state, and ZIP code | City, state, and ZIP code | May $ 7 |
Nov. $ 13 |
| June $ 8 |
Dec. $ 14 |
Form 1099-H Cat. No. 34192D 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
Health
Payments
Copy A
For Internal Revenue
Service Center File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act Notice, see the
2003 General Instructions for Forms 1099, 1098,
5498, and W-2G.
| PROVIDER’S name, street address, city, state, ZIP code, and telephone no. | 1Gross amount of health insurance advance payments $ |
OMB No. 1545-XXXX 2003 Form 1099-H |
|
|---|---|---|---|
| PROVIDER’S name, street address, city, state, ZIP code, and telephone no. |
PROVIDER’S name, street address, city, state, ZIP code, and telephone no. |
No. of months eligible 2 |
No. of months eligible 2 |
| PROVIDER’S name, street address, city, state, ZIP code, and telephone no. |
PROVIDER’S name, street address, city, state, ZIP code, and telephone no. |
Amount of advance payment(s) included in box 1 | Amount of advance payment(s) included in box 1 |
| PROVIDER’S Federal identification number | RECIPIENT’S identification number | Jan. $ 3 |
July $ 9 |
| RECIPIENT’S name | RECIPIENT’S name | Feb. $ 4 |
Aug. $ 10 |
| RECIPIENT’S name | RECIPIENT’S name | Mar. $ 5 |
Sept. $ 11 |
| 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.) | Apr. $ 6 |
Oct. $ 12 |
| City, state, and ZIP code | City, state, and ZIP code | City, state, and ZIP code | City, state, and ZIP code |
| City, state, and ZIP code | City, state, and ZIP code | May $ 7 |
Nov. $ 13 |
| June $ 8 |
Dec. $ 14 |
Form 1099-H Cat. No. 34192D 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
Health
Payments
Copy A
For Internal Revenue
Service Center File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act Notice, see the
2003 General Instructions for Forms 1099, 1098,
5498, and W-2G.
| PROVIDER’S name, street address, city, state, ZIP code, and telephone no. | 1Gross amount of health insurance advance payments $ |
OMB No. 1545-XXXX 2003 Form 1099-H |
|
|---|---|---|---|
| PROVIDER’S name, street address, city, state, ZIP code, and telephone no. |
PROVIDER’S name, street address, city, state, ZIP code, and telephone no. |
No. of months eligible 2 |
No. of months eligible 2 |
| PROVIDER’S name, street address, city, state, ZIP code, and telephone no. |
PROVIDER’S name, street address, city, state, ZIP code, and telephone no. |
Amount of advance payment(s) included in box 1 | Amount of advance payment(s) included in box 1 |
| PROVIDER’S Federal identification number | RECIPIENT’S identification number | Jan. $ 3 |
July $ 9 |
| RECIPIENT’S name | RECIPIENT’S name | Feb. $ 4 |
Aug. $ 10 |
| RECIPIENT’S name | RECIPIENT’S name | Mar. $ 5 |
Sept. $ 11 |
| 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.) | Apr. $ 6 |
Oct. $ 12 |
| City, state, and ZIP code | City, state, and ZIP code | City, state, and ZIP code | City, state, and ZIP code |
| City, state, and ZIP code | City, state, and ZIP code | May $ 7 |
Nov. $ 13 |
| June $ 8 |
Dec. $ 14 |
Form 1099-H Cat. No. 34192D Department of the Treasury - Internal Revenue Service
2003–16 I.R.B. 788 April 21, 2003
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