Form 8853 (2013)Attachment Sequence No.   39Page 2 

Name of policyholder (as shown on Form 1040)Social security number of 

policyholder a

Section C.  Long-Term Care (LTC) Insurance Contracts. See Filing Requirements for Section C  

before completing this section.

If more than one Section C is attached, check here ......................  a

14aName of insured  abSocial security number of insured  a

15In 2013, 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? .......................YesNo

16Was the insured a terminally ill individual?......................YesNo

Note:  

to you because the insured was terminally ill, skip lines 17 through 25 and enter -0- on line 26.

17Gross 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 .....................17

 use lines 18 through 26 to figure the taxable amount of benefits paid under an  

LTC insurance contract that is not a qualified 

 

 

Form 1040, line 21.

18Enter the part of the amount on line 17 that is from qualified LTC insurance contracts ....18

19Accelerated death benefits received on a per diem or other periodic basis. Do not include any 

amounts you received because the insured was terminally ill (see instructions) .......19

20Add lines 18 and 19..........................20

Note: If you checked “Yes” on line 15 above, see Multiple Payees in 

the instructions before completing lines 21 through 25.

21Multiply $320 by the number of days in the LTC period ......21

22Costs incurred for qualified LTC services provided for the insured 

during the LTC period (see instructions) ...........22

23Enter the larger of line 21 or line 22 ............23

24Reimbursements for qualified LTC services provided for the insured 

during the LTC period .................24

Caution: If you received any reimbursements from LTC contracts 

issued before August 1, 1996, see instructions.

25Per diem limitation. Subtract line 24 from line 23 .................25

26Taxable 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 ..............................26

Form 8853 (2013) 

FIRST NAMEMILAST NAMESUFF

not excludable from your income (for example, if the benefits are not paid for personal injuries or 

sickness through accident or health insurance), report the amount not excludable as income on 

If "Yes" and the only payments you received in 2013 were accelerated death benefits that were paid 

in the instructions

 LTC insurance contract. Instead, if the benefits are 

Caution: Do not

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