# Instructions for Form 8853

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8 Example 1 Step 1. They complete a statement for Step 4. Mrs. Smith, Sam, and Deborah Mrs. Smith was chronically ill throughout Mrs. Smith for the first LTC period as each complete Form 8853 as follows and received 12 monthly payments follows. Mrs. Smith s Form 8853: on a per diem basis from a qualified LTC Line Amount insurance contract. She was paid \$2,000 1st LTC 2nd LTC per month (\$24,000 total). Mrs. Smith Line Period Period Form \$12,000 (\$2,000 x 6 mos.) incurred expenses for qualified LTC services of \$150 per day (\$54,750) and 21 \$54,300 (\$300 x 181 days) 20 \$12,000 \$12,000 \$24,000 was reimbursed for one-half of those 22 \$27,150 (\$150 x 181 days) 25 \$40,725 \$12,000 \$52,725 expenses (\$27,375). She uses the equal 23 \$54, \$ -0- \$ -0- \$ -0- payment rate method and therefore has a single benefit period for 2011 (January 24 \$13,575 (\$75 x 181 days) Sam s Form 8853: 1 December 31). Mrs. Smith completes Form 8853, lines 20 through 26, as 25 \$40,725 1st LTC 2nd LTC follows. 26 \$ -0- Line Period Period Form 8853 Line Amount Step 2. They complete the aggregate 20 \$ -0- \$18,000 \$18,000 statement for the second LTC period as 20 \$24,000 (\$2,000 x 12 mos.) follows. 25 \$ -0- \$17,640 \$17, \$109,500 (\$300 x 365 days) 26 \$ -0- \$ 360 \$ 360 Line Amount 22 \$54,750 (\$150 x 365 days) Deborah s Form 8853: 20 \$42,000 (\$7,000 x 6 mos.) 23 \$109,500 1st LTC 2nd LTC 21 \$55,200 (\$300 x 184 days) 24 \$27,375 (\$75 x 365 days) Line Period Period Form \$27,600 (\$150 x 184 days) 25 \$82, \$ -0- \$12,000 \$12, \$55, \$ \$ -0- \$11,760 \$11, \$13,800 (\$75 x 184 days) Example 2 26 \$ -0- \$ 240 \$ \$41,400 The facts are the same as in Example 1, 26 \$600 except Mrs. Smith s son, Sam, and daughter, Deborah, each also own a Step 3. They allocate the aggregate per qualified LTC insurance contract under diem limitation of \$41,400 on line 25 which Mrs. Smith is the insured. Neither among Mrs. Smith, Sam, and Deborah. Sam nor Deborah incurred any costs for Because Mrs. Smith is the insured, the qualified LTC services for Mrs. Smith in per diem limitation is allocated first to her From July 1, 2011, through to the extent of the per diem payments December 31, 2011, Sam received per she received during the second LTC diem payments of \$3,000 per month period (\$12,000). The remaining per diem (\$18,000 total) and Deborah received per limitation of \$29,400 is allocated between diem payments of \$2,000 per month Sam and Deborah. (\$12,000 total). Mrs. Smith, Sam, and Allocation ratio to Sam: 60% of the Deborah agree to use the equal payment remaining limitation (\$17,640) is allocated rate method to determine their LTC to Sam because the \$18,000 he received periods. during the second LTC period is 60% of There are two LTC periods. The first is the \$30,000 received by both Sam and 181 days (from January 1 through June Deborah during the second LTC period. 30) during which the per diem payments Allocation ratio to Deborah: 40% of were \$2,000 per month. The second is the remaining limitation (\$11,760) is 184 days (from July 1 through December allocated to Deborah because the 31) during which the aggregate per diem \$12,000 she received during the second payments were \$7,000 per month (\$2,000 LTC period is 40% of the \$30,000 under Mrs. Smith s contract + \$3,000 received by both Sam and Deborah under Sam s contract + \$2,000 under during the second LTC period. Deborah s contract). An aggregate statement must be completed for the second LTC period and attached to Mrs. Smith s, Sam s, and Deborah s forms. -8- Instructions for Form 8853 (2011)

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