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9090
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OMB No. 1545-1813

Form 1099-H
(Rev. January 2022)
Health Coverage Tax Credit (HCTC) Advance Payments

For calendar year 20----

Copy A For Internal Revenue Service Center

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

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 TIN ----
RECIPIENT'S TIN ----
RECIPIENT'S name ----
Street address (including apt. no.) ----
City or town, state or province, country, and ZIP or foreign postal 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. $ ----

Form 1099-H (Rev. 1-2022)
Cat. No. 34912D
www.irs.gov/Form1099H
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

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-- CORRECTED (if checked)
OMB No. 1545-1813

Form 1099-H
(Rev. January 2022)
Health Coverage Tax Credit (HCTC) Advance Payments

For calendar year 20----

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. ----
ISSUER'S/PROVIDER'S TIN ----
RECIPIENT'S TIN ----
RECIPIENT'S name ----
Street address (including apt. no.) ----
City or town, state or province, country, and ZIP or foreign postal code ----
1 Amount of HCTC advance payments $ ----
2 No. of mos. of HCTC advance payments and reimbursement credits paid to you ----
3 Jan. $ ----
4 Feb. $ ----
5 Mar. $ ----
6 Apr. $ ----
7 May $ ----
8 June $ ----
9 July $ ----
10 Aug. $ ----
11 Sept. $ ----
12 Oct. $ ----
13 Nov. $ ----
14 Dec. $ ----

Form 1099-H (Rev. 1-2022)
(keep for your records)
www.irs.gov/Form1099H
Department of the Treasury - Internal Revenue Service

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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.

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-- VOID
-- CORRECTED
OMB No. 1545-1813

Form 1099-H
(Rev. January 2022)
Health Coverage Tax Credit (HCTC) Advance Payments

For calendar year 20----

Copy C For Issuer/Provider

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

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 TIN ----
RECIPIENT'S TIN ----
RECIPIENT'S name ----
Street address (including apt. no.) ----
City or town, state or province, country, and ZIP or foreign postal 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. $ ----

Form 1099-H (Rev. 1-2022)
www.irs.gov/Form1099H
Department of the Treasury - Internal Revenue Service

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Instructions for Issuer/Provider

To complete Form 1099-H, use:

• The current General Instructions for Certain Information Returns, and
• The current Instructions for Form 1099-H.

To order these instructions and additional forms, go to www.irs.gov/EmployerForms.

Filing and furnishing. For filing and furnishing instructions, including due dates, and requesting filing or furnishing extensions, see the current General Instructions for Certain Information Returns.

Need help? If you have questions about reporting on Form 1099-H, call the information reporting customer service site toll free at 866-455-7438 or 304-263-8700 (not toll free). Persons with a hearing or speech disability with access to TTY/TDD equipment can call 304-579-4827 (not toll free).

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Department of the Treasury
Internal Revenue Service
Nov 19, 2020
Cat. No. 49264S

Instructions for Form 1099-H
(Rev. December 2020)
Health Coverage Tax Credit (HCTC) Advance Payments

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

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 IRS.gov/Form1099H.

Reminders

General instructions. In addition to these specific instructions, you should also use the current General Instructions for Certain Information Returns. Those general instructions include information about the following topics.

• Backup withholding.
• Electronic reporting.
• Penalties.
• Who must file.
• When and where to file.
• Taxpayer identification numbers (TINs).
• Statements to recipients.
• Corrected and void returns.
• Other general topics.

You can get the general instructions from General Instructions for Certain Information Returns at IRS.gov/1099GeneralInstructions or go to IRS.gov/Form1099H.

Continuous-use form and instructions. Form 1099-H and these instructions have been converted from an annual revision to continuous use. Both the form and instructions will be updated as needed. For the most recent version, go to IRS.gov/Form1099H.

Specific Instructions

File Form 1099-H if you received any advance payments during the calendar year of qualified health insurance payments for the benefit of recipients of eligible trade adjustment assistance (TAA), Alternative TAA (ATAA), Reemployment TAA (RTAA); or Pension Benefit Guaranty Corporation (PBGC) payees, and their qualifying family members. These individuals are referred to in these instructions as recipients.

Who Must File

Section 6050T requires providers of qualified health insurance coverage (defined in section 35(e)) that receive advance payments of the HCTC from the Department of the Treasury on behalf of eligible recipients (pursuant to section 7527) to file Forms 1099-H to report those advance payments and to furnish a statement reporting that information to the recipient.

However, Notice 2004-47, 2004-29 I.R.B. 48, available at IRS.gov/irb/2004-29_IRB#NOT-2004-47, provides that the IRS HCTC Program (formerly the IRS HCTC Transaction Center), as an administrator of the 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 Program for this purpose by emailing the HCTC Program at wi.hctc.stakehldr.en@irs.gov. Unless you notify the HCTC Program of your intent to file information returns and furnish statements, you will be considered to have elected to have the HCTC Program file Form 1099-H and furnish statements to recipients in satisfying section 6050T filing and furnishing requirements.

How To File

For filing with the IRS, see part E in the current General Instructions for Certain Information Returns and Pub. 1220.

Statements to Recipients

If you are required to file Form 1099-H, a statement must be furnished to the recipient. The HCTC Program will furnish a copy of Form 1099-H or an acceptable substitute statement to each recipient on your behalf, unless you elect to file Form 1099-H and furnish the copy or substitute statement yourself. If you make this election, you may fill out the form, found online at IRS.gov/Form1099H, and send Copy B to the recipient. See part J in the current General Instructions for Certain Information Returns.

Truncating recipient's TIN on recipient statements. Pursuant to Treasury Regulations section 301.6109-4, all filers of this form may truncate a recipient's TIN (social security number (SSN), individual taxpayer identification number (ITIN), or adoption taxpayer identification number (ATIN)) on recipient statements. Truncation is not allowed on any documents the filer files with the IRS. A filer's TIN may not be truncated on any form. See part J in the current General Instructions for Certain Information Returns.

CAUTION! Expired ITINs may continue to be used for information return purposes regardless of whether they have expired for individual income tax return filing purposes. See part J in the current General Instructions for Certain Information Returns.

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. The HCTC Program will furnish a copy of Form 1099-H or an acceptable substitute statement to each recipient on your behalf, unless you elect to file Form 1099-H and furnish the copy or substitute statement yourself. The IRS will not assert the penalties imposed by sections 6721 and 6722 for information returns and statements required to be filed

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and furnished under section 6050T against you if you allow the HCTC Program to file and furnish Forms 1099-H. If you elect not to allow the HCTC Program 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 current 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 through December 31 of the current year. The amount received for the current year cannot exceed 72.5% of the total health insurance premium for the individual.

Box 2-No. of Mos. 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 Through 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.

