Form 8853 - Archer Msas And Long-Term Care Insurance Contracts - 2017 Page 2
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Form 8853 (2017)
Attachment Sequence No.
Page
Name of policyholder (as shown on Form 1040)
Social security number of
policyholder
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Section C. Long-Term Care (LTC) Insurance Contracts. See Filing Requirements for Section C in the instructions
before completing this section.
If more than one Section C is attached, check here .
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14a Name of insured
b Social security number of insured
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15
In 2017, did anyone other than you receive payments on a per diem or other periodic basis under a
qualified LTC insurance contract covering the insured or receive accelerated death benefits under a life
insurance policy covering the insured? .
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Yes
No
16
Yes
No
Was the insured a terminally ill individual? .
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Note: If “Yes” and the only payments you received in 2017 were accelerated death benefits that were paid
to you because the insured was terminally ill, skip lines 17 through 25 and enter -0- on line 26.
17
Gross LTC payments received on a per diem or other periodic basis. Enter the total of the
amounts from box 1 of all Forms 1099-LTC you received with respect to the insured on which the
“Per diem” box in box 3 is checked .
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17
Caution: Don't use lines 18 through 26 to figure the taxable amount of benefits paid under an
LTC insurance contract that isn't a qualified LTC insurance contract. Instead, if the benefits aren't
excludable from your income (for example, if the benefits aren't paid for personal injuries or
sickness through accident or health insurance), report the amount not excludable as income on
Form 1040, line 21.
18
Enter the part of the amount on line 17 that is from qualified LTC insurance contracts
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18
19
Accelerated death benefits received on a per diem or other periodic basis. Don't include any
amounts you received because the insured was terminally ill (see instructions) .
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19
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20
Add lines 18 and 19
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Note: If you checked “Yes” on line 15 above, see Multiple Payees in
the instructions before completing lines 21 through 25.
21
21
Multiply $360 by the number of days in the LTC period .
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22
Costs incurred for qualified LTC services provided for the insured
during the LTC period (see instructions) .
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22
23
Enter the larger of line 21 or line 22 .
23
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24
Reimbursements for qualified LTC services provided for the insured
during the LTC period .
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24
Caution: If you received any reimbursements from LTC contracts
issued before August 1, 1996, see instructions.
25
Per diem limitation. Subtract line 24 from line 23 .
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25
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Taxable payments. Subtract line 25 from line 20. If zero or less, enter -0-. Also include this
amount 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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8853
Form
(2017)
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