Form 8853 - Archer Msas And Long-Term Care Insurance Contracts Page 2
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Form 8853 (2008)
Attachment Sequence No.
Page
Name of policyholder (as shown on Form 1040)
Social security number
of policyholder
Section C. Long-Term Care (LTC) Insurance Contracts. See Filing Requirements for Section C on page 6 of
the instructions before completing this section.
If more than one Section C is attached, check here
16a Name of insured
b Social security number of insured
17
In 2008, did anyone other than you receive payments on a per diem or other periodic basis under a qualified
LTC insurance contract covering the insured or receive accelerated death benefits under a life insurance
Yes
No
policy covering the insured?
18
Was the insured a terminally ill individual?
Yes
No
Note: If “Yes” and the only payments you received in 2008 were accelerated death benefits that were paid
to you because the insured was terminally ill, skip lines 19 through 27 and enter -0- on line 28.
19
Gross LTC payments received on a per diem or other periodic basis. Enter the total of the amounts
from box 1 of all Forms 1099-LTC you received with respect to the insured on which the “Per
19
diem” box in box 3 is checked
Caution: Do not use lines 20 through 28 to figure the taxable amount of benefits paid under an
LTC insurance contract that is not a qualified LTC insurance contract. Instead, if the benefits
are not excludable from your income (for example, if the benefits are not paid for personal injuries
or sickness through accident or health insurance), report the amount not excludable as income
on Form 1040, line 21.
20
20
Enter the part of the amount on line 19 that is from qualified LTC insurance contracts
21
Accelerated death benefits received on a per diem or other periodic basis. Do not include any
21
amounts you received because the insured was terminally ill (see page 7 of the instructions)
22
22
Add lines 20 and 21
Note: If you checked “Yes” on line 17 above, see Multiple Payees
on page 7 of the instructions before completing lines 23 through 27.
23
23
Multiply $270 by the number of days in the LTC period
24
Costs incurred for qualified LTC services provided for the insured
24
during the LTC period (see page 7 of the instructions)
25
25
Enter the larger of line 23 or line 24
26
Reimbursements for qualified LTC services provided for the insured
26
during the LTC period
Caution: If you received any reimbursements from LTC contracts
issued before August 1, 1996, see page 7 of the instructions.
27
27
Per diem limitation. Subtract line 26 from line 25
28
Taxable payments. Subtract line 27 from line 22. If zero or less, enter -0-. Also include this
amount in the total on Form 1040, line 21. On the dotted line next to line 21, enter “LTC” and
the amount
28
8853
Form
(2008)
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