Looking for a Form 8853 Templates? Download it for free!

diem payments of $1,800 per month

among Mrs. Smith, Sam, and Deborah.

($10,800 total). Mrs. Smith, Sam, and

Because Mrs. Smith is the insured, the

Paperwork Reduction Act Notice. We

Deborah agree to use the equal payment

per diem limitation is allocated first to her

ask for the information on this form to

rate method to determine their LTC

to the extent of the per diem payments

carry out the Internal Revenue laws of the

periods.

she received during the second LTC

United States. You are required to give us

period ($12,000). The remaining per diem

the information. We need it to ensure that

There are two LTC periods. The first is

limitation of $19,280 is allocated between

you are complying with these laws and to

181 days (from January 1 through June

Sam and Deborah.

allow us to figure and collect the right

30) during which the per diem payments

amount of tax.

Allocation ratio to Sam: 60% of the

were $2,000 per month. The second is

remaining limitation is allocated to Sam

184 days (from July 1 through December

You are not required to provide the

because the $16,200 he received during

31) during which the aggregate per diem

information requested on a form that is

the second LTC period is 60% of the

payments were $6,500 per month ($2,000

subject to the Paperwork Reduction Act

$27,000 received by both Sam and

under Mrs. Smith’s contract + $2,700

unless the form displays a valid OMB

Deborah during the second LTC period.

under Sam’s contract + $1,800 under

control number. Books or records relating

Deborah’s contract).

to a form or its instructions must be

Allocation ratio to Deborah: 40% of

retained as long as their contents may

the remaining limitation is allocated to

An aggregate statement must be

become material in the administration of

Deborah because the $10,800 she

completed for the second LTC period and

any Internal Revenue law. Generally, tax

received during the second LTC period is

attached to Mrs. Smith’s, Sam’s, and

returns and return information are

40% of the $27,000 received by both Sam

Deborah’s forms.

confidential, as required by section 6103.

and Deborah during the second LTC

Step 1. They complete a statement for

period.

The time needed to complete and file

Mrs. Smith for the first LTC period as

this form will vary depending on individual

Step 4. Mrs. Smith, Sam, and Deborah

follows.

circumstances. The estimated average

each complete Form 8853 as follows.

time is:

Mrs. Smith’s Form 8853:

Line

Amount

Recordkeeping . . . . . . . . 1 hr., 31 min.

1st LTC

2nd LTC

$12,000 ($2,000 x 6 mos.)

Line

Period

Form 8853

Learning about the law or

$39,820 ($220 x 181 days)

the form . . . . . . . . . . . . .

34 min.

$12,000

$24,000

$18,100 ($100 x 181 days)

Preparing the form . . . . . 1 hr., 42 min.

$30,770

$12,000

$42,770

$39,820

Copying, assembling, and

$ -0-

$-0-

$9,050 ($50 x 181 days)

sending the form to the

$30,770

Sam’s Form 8853:

IRS . . . . . . . . . . . . . . . . .

46 min.

$ -0-

1st LTC

2nd LTC

If you have comments concerning the

Step 2. They complete the aggregate

Line

Period

Form 8853

accuracy of these time estimates or

statement for the second LTC period as

suggestions for making this form simpler,

follows.

$-0-

$16,200

we would be happy to hear from you. See

the Instructions for Form 1040.

$-0-

$11,568

Line

Amount

$-0-

$4,632

$39,000 ($6,500 x 6 mos.)

Deborah’s Form 8853:

$40,480 ($220 x 184 days)

1st LTC

2nd LTC

$18,400 ($100 x 184 days)

Line

Period

Form 8853

$40,480

$-0-

$10,800

$9,200 ($50 x 184 days)

$-0-

$7,712

$31,280

$-0-

$3,088

$7,720

Step 3. They allocate the aggregate per

diem limitation of $31,280 on line 27

-8-

Instructions For Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2003 Page 8

Related Articles

Related forms

Related Categories