Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2004 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 this page.
Start Here
Did you (or your spouse, if
filing jointly) receive
Were any of those
Complete all of
payments in 2004 made on
payments made
Yes
Yes
Section C
a per diem or other periodic
under a qualified LTC
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 2004 from a life
2004 from a life insurance
No
16a, 16b, and 19 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 16a,
paid on behalf of a
16b, 17, 18, 19 (if
No
Yes
No
chronically ill (not terminally
applicable), and 28 of
ill) individual?
Section C
Yes
Do not complete
Complete all of Section C
Section C
Per Diem Payments
the additional 50% tax to enter on line
holder is considered to be the
15b.
policyholder.
Per diem payments are payments of a
fixed amount made on a periodic basis
Qualified LTC Insurance Contract
without regard to actual expenses
Section C—Long-Term
A qualified LTC insurance contract is a
incurred. Box 3 of Form 1099-LTC should
contract issued:
Care (LTC) Insurance
indicate whether payments were per diem
•
After December 31, 1996, that meets
payments.
Contracts
the requirements of section 7702B,
including the requirement that the insured
See Filing Requirements for Section C
Chronically Ill Individual
must be a chronically ill individual
above.
A chronically ill individual is someone who
(defined on this page), or
•
has been certified (at least annually) by a
Before January 1, 1997, that met state
Definitions
licensed health care practitioner as —
law requirements for LTC insurance
•
contracts at the time the contract was
Being unable to perform at least two
Policyholder
issued and has not been changed
activities of daily living (ADLs) (eating,
The policyholder is the person who owns
materially.
toileting, transferring, bathing, dressing,
the proceeds of the LTC insurance
and continence), without substantial
contract, life insurance contract, or viatical
In general, amounts paid under a
assistance from another individual, for at
settlement and also may be the insured
qualified LTC insurance contract are
least 90 days, due to a loss of functional
individual. The policyholder is required to
excluded from your income. However, if
capacity, or
report the income, even if payment is
you receive per diem payments (defined
•
assigned to a third party or parties. In the
next), the amount you can exclude is
Requiring substantial supervision to
case of a group contract, the certificate
limited.
protect the individual from threats to
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