Instructions For Form 8853 - 2011 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
ling jointly) receive
Were any of those
payments in 2011 made on
payments made
Complete all of
Ye s
Ye s
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
ling jointly) receive any
ling jointly) receive any
accelerated death bene ts in
accelerated death bene ts in
Complete only lines
2011 from a life
2011 from a life insurance
14a, 14b, and 17 of
No
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?
Ye s
Were any of the payments
Complete only lines 14a,
paid on behalf of a
14b, 15, 16, 17 (if
Ye s
No
No
chronically ill (not terminally
applicable), and 26 of
ill) individual?
Section C
Ye s
Do not complete
Complete all of Section C
Section C
•
Chronically Ill Individual
Before January 1, 1997, that met state
settlements are fully excludable from your
gross income if the insured is a terminally
law requirements for LTC insurance
A chronically ill individual is someone who
ill individual (defined below). Accelerated
contracts at the time the contract was
has been certified (at least annually) by a
death benefits paid with respect to an
issued and has not been changed
licensed health care practitioner as —
insured individual who is chronically ill
•
materially.
Being unable to perform at least two
generally are excludable from your gross
activities of daily living (eating, toileting,
income to the same extent as they would
In general, amounts paid under a
transferring, bathing, dressing, and
be under a qualified LTC insurance
qualified LTC insurance contract are
continence), without substantial
contract.
excluded from your income. However, if
assistance from another individual, for at
you receive per diem payments (defined
least 90 days, due to a loss of functional
Terminally Ill Individual
below), the amount you can exclude is
capacity, or
A terminally ill individual is any individual
•
limited.
Requiring substantial supervision to
who has been certified by a physician as
protect the individual from threats to
having an illness or physical condition
Per Diem Payments
health and safety due to severe cognitive
that can reasonably be expected to result
impairment.
Per diem payments are payments of a
in death within 24 months of the date of
fixed amount made on a periodic basis
certification.
Accelerated Death Benefits
without regard to actual expenses
Line 15
incurred. Box 3 of Form 1099-LTC should
Generally, amounts paid as accelerated
indicate whether payments were per diem
death benefits under a life insurance
Special rules apply in determining the
payments.
contract or under certain viatical
taxable payments if other individuals
-6-
Instructions for Form 8853 (2011)
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