Instructions For Form 8853 - 2009 Page 6
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8Filing Requirements for Section C
Go through this chart for each insured person for
whom you received long-term care (LTC)
payments. See Definitions that begin on page 5.
Start Here
Did you (or your spouse, if
filing jointly) receive
Were any of those
payments in 2009 made on
payments made
Complete all of
Yes
Yes
a per diem or other periodic
under a qualified LTC
Section C
basis under an LTC
insurance contract?
insurance contract?
No
No
Did you (or your spouse, if
Did you (or your spouse, if
filing jointly) receive any
filing jointly) receive any
accelerated death benefits
accelerated death benefits in
Complete only lines
in 2009 from a life
2009 from a life insurance
No
14a, 14b, and 17 of
insurance policy that were
policy that were made on a
Section C
made on a per diem or
per diem or other periodic
other periodic basis?
basis?
Yes
Were any of the payments
Complete only lines 14a,
paid on behalf of a
14b, 15, 16, 17 (if
No
Yes
No
chronically ill (not terminally
applicable), and 26 of
ill) individual?
Section C
Yes
Do not complete
Complete all of Section C
Section C
•
•
Before January 1, 1997, that met state
Being unable to perform at least two
chronically ill generally are excludable
law requirements for LTC insurance
activities of daily living (eating, toileting,
from your gross income to the same
contracts at the time the contract was
transferring, bathing, dressing, and
extent as they would be under a qualified
issued and has not been changed
continence), without substantial
LTC insurance contract.
materially.
assistance from another individual, for at
least 90 days, due to a loss of functional
In general, amounts paid under a
Terminally Ill Individual
capacity, or
qualified LTC insurance contract are
•
Requiring substantial supervision to
A terminally ill individual is any individual
excluded from your income. However, if
protect the individual from threats to
who has been certified by a physician as
you receive per diem payments (defined
health and safety due to severe cognitive
having an illness or physical condition
below), the amount you can exclude is
impairment.
that can reasonably be expected to result
limited.
Accelerated Death Benefits
in death within 24 months of the date of
Per Diem Payments
certification.
Generally, amounts paid as accelerated
Per diem payments are payments of a
death benefits under a life insurance
fixed amount made on a periodic basis
contract or under certain viatical
Line 15
without regard to actual expenses
settlements are fully excludable from your
incurred. Box 3 of Form 1099-LTC should
gross income if the insured is a terminally
Special rules apply in determining the
indicate whether payments were per diem
ill individual (defined on this page).
taxable payments if other individuals
payments.
Accelerated death benefits paid with
received per diem payments under a
respect to an insured individual who is
Chronically Ill Individual
qualified LTC insurance contract or as
accelerated death benefits with respect to
A chronically ill individual is someone who
the insured listed on line 14a. See
has been certified (at least annually) by a
Multiple Payees on page 7 for details.
licensed health care practitioner as —
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