Exhibit M
Internal Revenue Bulletin 2003-16 · 2026-10-03 edition · updated 2026-10-04 · United States
9393 - VOID CORRECTED 4.50"
OMB No. 1545-1519
Benefits
PAYER’S name, street address, city, state, ZIP code, and telephone no.
1 Gross long-term care benefits paid
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,
| $ | |||||
|---|---|---|---|---|---|
| Accelerated death benefits paid 2 $ |
|||||
| PAYER’S Federal identification number | POLICYHOLDER’S identification number | POLICYHOLDER’S identification number | Check one: 3 Per Reimbursed |
INSURED’S social security no. |
INSURED’S social security no. |
3.40" POLICYHOLDER’S name |
3.40" POLICYHOLDER’S name |
3.40" POLICYHOLDER’S name |
1.40" diem amount INSURED’S name |
1.40" diem amount INSURED’S name |
1.40" diem amount INSURED’S name |
| Street address (including apt. no.) | Street address (including apt. no.) | Street address (including apt. no.) | 2.80" Street address (including apt. no.) |
2.80" Street address (including apt. no.) |
2.80" Street address (including apt. no.) |
| 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 |
| Account number (optional) | Account number (optional) | Qualified contract (optional) 4 |
Terminally ill Chronically ill 5 Check, if applicable: (optional) |
Terminally ill Chronically ill 5 Check, if applicable: (optional) |
Date certified |
Form 1099-LTC 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
VOID CORRECTED
Benefits
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,
| PAYER’S name, street address, city, state, ZIP code, and telephone no. | 1Gross long-term care benefits paid $ |
OMB No. 1545-1519 2003 Form 1099-LTC |
|||||
|---|---|---|---|---|---|---|---|
| PAYER’S name, street address, city, state, ZIP code, and telephone no. | PAYER’S name, street address, city, state, ZIP code, and telephone no. | PAYER’S name, street address, city, state, ZIP code, and telephone no. | Accelerated death benefits paid 2 $ |
Accelerated death benefits paid 2 $ |
Accelerated death benefits paid 2 $ |
Accelerated death benefits paid 2 $ |
Accelerated death benefits paid 2 $ |
| PAYER’S Federal identification number | POLICYHOLDER’S identification number | POLICYHOLDER’S identification number | Check one: 3 Per diem Reimbursed amount |
Check one: 3 Per diem Reimbursed amount |
Check one: 3 Per diem Reimbursed amount |
INSURED’S social security no. | INSURED’S social security no. |
| POLICYHOLDER’S name | POLICYHOLDER’S name | POLICYHOLDER’S name | INSURED’S name | INSURED’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.) | Street address (including apt. no.) | Street address (including apt. no.) |
| 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 | City, state, and ZIP code | City, state, and ZIP code |
| Account number (optional) | Account number (optional) | Qualified contract (optional) 4 |
5 Check, if applicable: (optional) |
Terminally ill Chronically ill |
Terminally ill Chronically ill |
Date certified | |
| Account number (optional) | Account number (optional) | Qualified contract (optional) 4 |
5 Check, if applicable: (optional) |
Form 1099-LTC 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
Benefits
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,
| 9393 CORREC VOID | CTED | ||||||
|---|---|---|---|---|---|---|---|
| PAYER’S name, street address, city, state, ZIP code, and telephone no. | PAYER’S name, street address, city, state, ZIP code, and telephone no. | PAYER’S name, street address, city, state, ZIP code, and telephone no. | Gross long-term care benefits paid 1 $ |
Gross long-term care benefits paid 1 $ |
Gross long-term care benefits paid 1 $ |
OMB No. 1545-1519 Form 1099-LTC 2003 |
OMB No. 1545-1519 Form 1099-LTC 2003 |
| PAYER’S name, street address, city, state, ZIP code, and telephone no. | PAYER’S name, street address, city, state, ZIP code, and telephone no. | PAYER’S name, street address, city, state, ZIP code, and telephone no. | Accelerated death benefits paid 2 $ |
Accelerated death benefits paid 2 $ |
Accelerated death benefits paid 2 $ |
Accelerated death benefits paid 2 $ |
Accelerated death benefits paid 2 $ |
| PAYER’S Federal identification number | POLICYHOLDER’S identification number | POLICYHOLDER’S identification number | Check one: 3 Per diem Reimbursed amount |
Check one: 3 Per diem Reimbursed amount |
Check one: 3 Per diem Reimbursed amount |
INSURED’S social security no. | INSURED’S social security no. |
| POLICYHOLDER’S name | POLICYHOLDER’S name | POLICYHOLDER’S name | INSURED’S name | INSURED’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.) | Street address (including apt. no.) | Street address (including apt. no.) |
| 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 | City, state, and ZIP code | City, state, and ZIP code |
| Account number (optional) | Account number (optional) | Qualified contract (optional) 4 |
5 Check, if applicable: (optional) |
Terminally ill Chronically ill |
Terminally ill Chronically ill |
Date certified | |
| Account number (optional) | Account number (optional) | Qualified contract (optional) 4 |
5 Check, if applicable: (optional) |
Form 1099-LTC Cat. No. 23021Z Department of the Treasury - Internal Revenue Service
2003–16 I.R.B. 790 April 21, 2003
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