
Form 1099-H and Instructions 
Health Coverage Tax Credit (HCTC) Advance Payments
2011

Cat. No. 49264S

Department of the Treasury
Internal Revenue Service

In 1 File
Print pages 1-7 and 1

Provided by the IRS AMC
(Alternative Media Center)
2011


Contents

Section:  Page
Form 1099-H:  1
     Copy A--For IRS:  1
     Copy B--For Recipient:  2
     Instructions for Recipient:  3
     Copy 1--For Recipient (Issued by the HCTC Program):  4
     Instructions for Recipient:  5
     Copy C--For Payer:  6
     Instructions for Issuer/Provider:  7
2011 Instructions for Form 1099-H:  1
     What's New:  1
     Reminder:  1
     Specific Instructions:  1

This electronic edition contains the entire text of the print editions.
<page 1>

Form 1099-H
Health Coverage Tax Credit (HCTC) Advance Payments
2011

Copy A
For Internal Revenue Service Center

File with Form 1096.

VOID --; CORRECTED --
ISSUER'S/PROVIDER'S name, street address, city, state, ZIP code, and telephone no.: ----
ISSUER'S/PROVIDER'S federal identification no.: ----
RECIPIENT'S identification number: ----
RECIPIENT'S name: ----
Street address (including apt. no.): ----
City, state, and ZIP code: ----

1. Amount of HCTC advance payments: $----
2. No. of mos. HCTC payments received: ----
3. Jan.: $----
4. Feb.: $----
5. Mar.: $----
6. Apr.: $----
7. May: $----
8. June: $----
9. July: $----
10. Aug.: $----
11. Sept.: $----
12. Oct.: $----
13. Nov.: $----
14. Dec.: $----

For Privacy Act and Paperwork Reduction Act Notice, see the 2011 General Instructions for Certain Information Returns.

<page 2>

Form 1099-H
Health Coverage Tax Credit (HCTC) Advance Payments
2011

Copy B
For Recipient

CORRECTED (if checked) --
ISSUER'S/PROVIDER'S name, street address, city, state, ZIP code, and telephone no.: ----
ISSUER'S/PROVIDER'S federal identification no.: ----
RECIPIENT'S identification number: ----
RECIPIENT'S name: ----
Street address (including apt. no.): ----
City, state, and ZIP code: ----

1. Amount of HCTC advance payments: $----
2. No. of mos. HCTC payments received: ----
3. Jan.: $----
4. Feb.: $----
5. Mar.: $----
6. Apr.: $----
7. May: $----
8. June: $----
9. July: $----
10. Aug.: $----
11. Sept.: $----
12. Oct.: $----
13. Nov.: $----
14. Dec.: $----

This is important tax information and is being furnished to the Internal Revenue Service.

<page 3>

Instructions for Recipient

This statement is provided to you because you received HCTC advance payments of your health coverage insurance premiums. These advance payments were forwarded directly to your health insurance provider. You qualify to receive advance payments if you were an eligible trade adjustment assistance (TAA), Reemployment TAA, or a Pension Benefit Guaranty Corporation (PBGC) pension recipient. 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, 1040NR, 1040-SS, or 1040-PR.

Box 1. Shows the total amount of HCTC advance payments of qualified health insurance costs that were made on your behalf. Do not report this amount on Form 8885. This amount is in lieu of any credit you will be able to take on Form 1040, 1040NR, 1040-SS, or 1040-PR, because it was paid for you in advance.

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.

<page 4>

Form 1099-H
Health Coverage Tax Credit (HCTC) Advance Payments
2011

Copy 1
For Recipient
(Issued by the HCTC Program)

CORRECTED (if checked) --
ISSUER'S/PROVIDER'S name, street address, city, state, ZIP code, and telephone no.: ----
ISSUER'S/PROVIDER'S federal identification no.: ----
RECIPIENT'S identification number: ----
RECIPIENT'S name: ----
Street address (including apt. no.): ----
City, state, and ZIP code: ----

1. Amt. of HCTC advance payments and reimbursment credits paid to you: $----
2. No. of mos. HCTC advance payments and reimbursment credits received: ----
3. Jan.: $----
4. Feb.: $----
5. Mar.: $----
6. Apr.: $----
7. May: $----
8. June: $----
9. July: $----
10. Aug.: $----
11. Sept.: $----
12. Oct.: $----
13. Nov.: $----
14. Dec.: $----

This is important tax information and is being furnished to the Internal Revenue Service.

<page 5>

Instructions for Recipient

This statement is provided to you because the HCTC Program made monthly payment(s) to your health plan to cover a portion of your health insurance costs in 2011. These payments are referred to on this statement as advance payments. These advance payments are shown in Boxes 1 through 14 as follows:

Box 1. Shows the total amount of HCTC advance payments that were made on your behalf for the entire year, as well as the total amount of reimbursement credits paid to you prior to your HCTC enrollment.

Box 2. Shows the total number of months HCTC advance payments or reimbursement credits were made on your behalf.

Boxes 3 through 14. Shows the total amount of any HCTC advance payments or reimbursement credits that were made on your behalf each month. The sum of these amounts equals the amount shown in Box 1.

Note. This statement reflects the tax credit that you and any qualified family members received in 2011 through the monthly HCTC Program. It does not reflect payments you made to the HCTC Program ("U.S. Treasury--HCTC") which were forwarded to your health plan by the HCTC Program.

Any HCTC amount listed on this statement cannot be claimed on your federal income tax return. Claiming this amount means you would receive the credit twice. If you receive the credit for amounts you are not entitled to, you will be required to repay the IRS. Only payments you paid directly to your health plan can be claimed on your federal income tax return. This means any amounts for which you received an advance payment or reimbursement credit cannot be claimed on your tax return (any reimbursement credits will be reflected on this form). For example, if you paid $100 to your health plan and received an $80 advance payment or reimbursement credit, you cannot claim the same $100 on your tax return. Similarly, if you sent $20 to the HCTC Program to cover your portion of your monthly $100 health plan premium, you cannot claim that $20 payment on your tax return because you already received the $80 tax credit. See IRS Form 8885 for more information on these requirements.

Need help? If you have any questions regarding this statement, call the HCTC Customer Contact Center toll-free at 1-866-628-HCTC (4282). If you have a hearing impairment, call 1-866-626-4282 (TTY).  For general information about the HCTC, visit IRS.gov (keyword/Search: HCTC).

<page 6>

Form 1099-H
Health Coverage Tax Credit (HCTC) Advance Payments
2011

Copy C
For Payer

VOID --; CORRECTED --
ISSUER'S/PROVIDER'S name, street address, city, state, ZIP code, and telephone no.: ----
ISSUER'S/PROVIDER'S federal identification no.: ----
RECIPIENT'S identification number: ----
RECIPIENT'S name: ----
Street address (including apt. no.): ----
City, state, and ZIP code: ----

1. Amount of HCTC advance payments: $----
2. No. of mos. HCTC payments received: ----
3. Jan.: $----
4. Feb.: $----
5. Mar.: $----
6. Apr.: $----
7. May: $----
8. June: $----
9. July: $----
10. Aug.: $----
11. Sept.: $----
12. Oct.: $----
13. Nov.: $----
14. Dec.: $----

For Privacy Act and Paperwork Reduction Act Notice, see the 2011 General Instructions for Certain Information Returns.

<page 7>

Instructions for Issuer/Provider

General and specific form instructions are provided as separate products. These products are the 2011 General Instructions for Certain Information Returns and the 2011 Instructions for Form 1099-H. A chart in the general instructions gives a quick guide to which form must be filed to report a particular payment. To order these instructions and additional forms, visit IRS.gov or call 1-800-TAX-FORM (1-800-829-3676).

Caution: Because paper forms are scanned during processing, you cannot file with the IRS Forms 1096, 1097, 1098, 1099, 3921, 3922, or 5498 that you print from IRS.gov.

Due dates. Furnish Copy B of this form to the recipient by January 31, 2012. Copy 1 is furnished by the HCTC Transaction Center.

File Copy A of this form with the IRS by February 28, 2012. If you file electronically, the due date is April 2, 2012. To file electronically, you must have software that generates a file according to the specifications in Pub. 1220, Specifications for Filing Forms 1097, 1098, 1099, 3921, 3922, 5498, 8935, and W-2G Electronically. IRS does not provide a fill-in form option.

Need help? If you have questions about reporting on Form 1099-H, call the information reporting customer service site toll free at 1-866-455-7438 or 304-263-8700 (not toll free). For TTY/TDD equipment, call 304-579-4827 (not toll free). The hours of operation are Monday through Friday from 8:30 a.m. to 4:30 p.m., Eastern time.

<page 1>

2011 Instructions for Form 1099-H

Section references are to the Internal Revenue Code unless otherwise noted.

What's New

Pilot program for truncating an individual's identifying number on paper payee statements has ended. Filers of Form 1099-H must show the recipient's complete identifying number on all copies of the form.

Copy 1. Form 1099-H includes Copy 1, provided to recipients by the IRS Health Coverage Tax Credit (HCTC) Transaction Center. Copy B must be provided to recipients by all other filers.

Reminder

In addition to these specific instructions, you should also use the 2011 General Instructions for Certain Information Returns (Forms 1097, 1098, 1099, 3921, 3922, 5498, and W-2G). Those general instructions include information about the following topics.
-- Backup withholding.
-- Electronic reporting requirements.
-- Penalties.
-- Who must file (nominee/middleman).
-- When and where to file.
-- Taxpayer identification numbers.
-- Statements to recipients.
-- Corrected and void returns.
-- Other general topics.

You can get the general instructions at IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676).

Specific Instructions

File Form 1099-H, Health Coverage Tax Credit (HCTC) Advance Payments, if you received in the course of your trade or business any advance payments during the calendar year of qualified health insurance payments for the benefit of eligible trade adjustment assistance (TAA), Reemployment TAA, or Pension Benefit Guaranty Corporation (PBGC) recipients and their qualifying family members.

Who Must File

Section 6050T requires that if you are a provider of qualified health insurance coverage (section 35(e)) you must file Forms 1099-H with the IRS reporting the advance payments that you receive from the Department of the Treasury on behalf of eligible individuals. You must also furnish a statement to the eligible recipient.

However, Notice 2004-47, 2004-29 I.R.B. 48, available at www.irs.gov/irb/2004-29_IRB/ar11.html, provides that the HCTC Transaction Center, as an administrator of the Health Coverage Tax Credit (HCTC), will file the required returns and furnish statements to the recipients unless you elect to file and furnish information returns and statements on your own. Contact the HCTC Transaction Center for this purpose by calling 1-866-628-4282. Unless you notify the HCTC Transaction Center of your intent to file information returns and furnish statements, you will be considered to have elected to have the Transaction Center file Form 1099-H and furnish statements to recipients in satisfying section 6050T filing requirements.

Statements to Recipients

If you are required to file Form 1099-H, a statement must be furnished to the recipient. You or the Transaction Center, if elected, must furnish a copy of Form 1099-H or an acceptable substitute statement to each recipient. Also, see part M in the 2011 General Instructions for Certain Information Returns.

Penalties

Waiver of penalties. Section 6724(a) authorizes the IRS to waive any penalties under sections 6721 and 6722 for failure to comply with the reporting requirements of section 6050T if such failures resulted from reasonable cause and not willful neglect. If you elect to allow the HCTC Transaction Center to file and furnish Forms 1099-H, the IRS will not assert the penalties imposed by sections 6721 and 6722 regarding the reporting of advance payments made to you. If you do not elect to allow the HCTC Transaction Center to file and furnish Forms 1099-H, the general rules for seeking a penalty waiver under section 6724(a) apply. See Regulations section 301.6724-1.

For more information on penalties, see part O in the 2011 General Instructions for Certain Information Returns.

Box 1. Amount of HCTC Advance Payments

Enter the total amount of advance payments of health insurance premiums received on behalf of the recipient for the period January 1, 2011, through December 31, 2011. The amount received in 2011 cannot exceed 65% of the total health insurance premium for the individual.

Box 2. No. of Months HCTC Payments Received

Enter the number of months payments were received on behalf of the recipient. This number cannot be more than 12.

Boxes 3-14. Amount of Advance Payment(s) Included in Box 1

Enter the amount of the advance payment received for each month in the applicable box. You may receive these payments prior to the month for which they are paid. Be sure to enter the amounts in the correct box.

End of Form 1099-H and Instructions