Form 712 Life Insurance Statement

47 Face amount 50 Frequency of payment 55 Date of birth if known Amount of premium (see instructions) 13 Assignor s name Attach copy of assignment 10 Date assigned11 Date assigned52 Date designated 56 Date issued9 Issue date48 Last name37 Name of beneficiaries14 No Off No Off Policy number46 Policy number7 Sex54 Social security number38 (File with Form 709 United States Gift (and Generation Skipping Transfer) Tax Return May also be filed with Form 706 United States Estate (and Generation Skipping Transfer) Tax Return or Form 706 NA United States Estate (and Generation Skipping Transfer) Tax Return Estate of nonresident not a citizen of the United States where decedent owned insurance on life of another ) (Rev April 2006) 12 Value of the policy at the time of assignment 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Face amount of policy Indemnity benefits Additional insurance Other benefits Principal of any indebtedness to the company that is deductible in determining net proceeds Interest on indebtedness (line 19) accrued to date of death Amount of accumulated dividends Amount of post mortem dividends Amount of returned premium Amount of proceeds if payable in one sum Value of proceeds as of date of death (if not payable in one sum) Policy provisions concerning deferred payments or installments Note If other than lump sum settlement is authorized for a surviving spouse attach a copy of the insurance policy Amount of installments Date of birth sex and name of any person the duration of whose life may measure the number of payments Amount applied by the insurance company as a single premium representing the purchase of installment benefits 30 Basis (mortality table and rate of interest) used by insurer in valuing installment benefits 31 Were there any transfers of the policy within the three years prior to the death of the decedent? Yes Off 32 Date of assignment or transfer: 33 Was the insured the annuitant or beneficiary of any annuity contract issued by the company? Yes Off 34 Did the decedent have any incidents of ownership on any policies on his/her life but not owned by 35 Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by your records 36 First name and middle initial of donor (or decedent) 39 Date of gift for which valuation data submitted 40 Date of decedent s death for which valuation data submitted 45 Type of policy 49 Gross premium 51 Assignee s name 53 If irrevocable designation of beneficiary made name of beneficiary 57 If other than simple designation quote in full Attach additional sheets if necessary 6 Type of policy 8 Owner s name If decedent is not owner attach copy of application Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law Certification cumulative premium to date of death Date of Certification Date of Signature Title Decedent Insured (To be filed by the executor with Form 706 United States Estate (and Generation Skipping Transfer) Tax Return or each policy For Paperwork Reduction Act Notice see page 3 Cat No 10170V Form 712 (Rev 4 2006) For purposes of this statement a facsimile signature may be used in lieu of a manual signature and if used shall be binding as a manual signature Form 706 NA United States Estate (and Generation Skipping Transfer) Tax Return Estate of nonresident not a citizen of the United States ) Generally tax returns and return information are confidential as required by section 6103 him/her at the date of death? Yes Off If death occurred after the end of the premium period report the last annual premium If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler we would be happy to hear from you Instructions Learning about the form 6 min Life Insurance Statement Line 13 Report on line 13 the annual premium not the Living Insured Month Day Year Name and address of insurance company OMB No 1545 0022 Department of the Treasury Internal Revenue Service Paperwork Reduction Act Notice We ask for the information on this form to carry out the Internal Revenue laws of the United States You are required to give us the information We need it to ensure that you are complying with these laws and to allow us to figure and collect the right amount of tax Preparing the form 23 min Printed on recycled paper Recordkeeping 18 hrs 11 min requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number SECTION A General Information SECTION B Policy Information See the instructions for the tax return with which this form is filed Do not send the tax form to that office Instead return it to the executor or representative who requested it Separate statements File a separate Form 712 for Signature Title Statement of insurer This statement must be made on behalf of the insurance company that issued the policy by an officer of the company having access to the records of the company The estimated average time is: The time needed to complete and file this form will vary depending on individual circumstances The undersigned officer of the above named insurance company (or appropriate federal agency or retirement system official) hereby certifies that this statement sets forth true and correct information You are not required to provide the information