Form 8853 - Medical Savings Accounts And Long-Term Care Insurance Contracts - 1998 Page 2
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Form 8853 (1998)
Attachment Sequence No.
Page
Name of policyholder (as shown on Form 1040)
Social security number
of policyholder
Section B. Long-Term Care (LTC) Insurance Contracts—See the instructions, including Filing Requirements for
Section B on page 6, before completing this section.
If more than one Section B is attached, check here
b Social security number of insured
12a Name of insured
13
Are there individuals other than you who received payments on a per diem or other periodic basis in 1998
under a qualified LTC insurance contract, or received accelerated death benefits in 1998 under a life
Yes
No
insurance policy, covering the insured listed on line 12a above?
14
Was the insured a terminally ill individual?
Yes
No
Note: If “ Yes,” and if the only payments you received dur ing the year were accelerated death benefits received because the
insured was terminally ill, skip lines 15 through 23 and enter -0- on line 24.
15
Gross LTC payments received on a per diem or other periodic basis. Enter the total amounts
from box 1 of all Forms 1099-LTC that you received with respect to the insured listed on line
15
12a above if the “Per diem” box is checked in box 3 of Form 1099-LTC
Caution: Do not use lines 16 through 24 below to figure the taxable amount of benefits paid under
any LTC insurance contract other than a qualified LTC insurance contract. Instead, to the extent
these amounts are not excludable from your income under the applicable provisions of the Internal
Revenue Code (for example, if the benefits are not paid for personal injuries or sickness through
accident or health insurance), report these amounts directly on Form 1040, line 21.
16
Enter the portion of the amount you entered on line 15 that is from qualified LTC insurance
16
contracts
17
Accelerated death benefits received on a per diem or other periodic basis.
Note: If you checked the “ Yes” box in question 14 above, do not include on line 17 amounts
17
received because the insured was terminally ill. See instructions
18
18
Add lines 16 and 17
If you checked “ Yes” to the question on line 13 above, see the
instructions for line 13 before completing lines 19 through 23.
19
19
Multiply $180 by the number of days of the LTC period
20
Enter the costs incurred for qualified LTC services provided for the
20
insured during the LTC period (see instructions)
21
21
Enter the larger of line 19 or line 20
22
Enter total reimbursements received for qualified LTC services
22
provided for the insured during the LTC period
Caution: If you received any reimbursements from LTC contracts
issued before August 1, 1996, see instructions.
23
23
Per diem limitation. Subtract line 22 from line 21
24
Taxable payments. Subtract line 23 from line 18. Enter the result but do not enter less than
zero. If the result is more than zero, also include it in the total on Form 1040, line 21. On the
dotted line next to line 21, enter “LTC” and the amount
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