Form 712 - Life Insurance Statement (Rev. November 1991)

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712
Form
OMB No. 1545-0022
Life Insurance Statement
(Rev. November 1991)
Department of the Treasury
Expires 11-30-94
Internal Revenue Service
Decedent—Insured (To Be Filed With United States Estate Tax Return, Form 706)
Part I
1
Decedent’s first name and middle initial
2
Decedent’s last name
3
Decedent’s social security number
4
Date of death
(if known)
5
Name and address of insurance company
6
Type of policy
7
Policy number
8
Owner’s name. If decedent is not owner,
9
Date issued
10
Assignor’s name. Please attach
11
Date assigned
please attach copy of application.
copy of assignment.
12
Value of the policy at the
13
Amount of premium (see instructions)
14
Name of beneficiaries
time of assignment
$
15
Face amount of policy
$
16
Indemnity benefits
$
17
Additional insurance
$
18
Other benefits
$
19
Principal of any indebtedness to the company that is deductible in determining net proceeds
$
20
Interest on indebtedness (item 19) accrued to date of death
$
21
Amount of accumulated dividends
$
22
Amount of post-mortem dividends
$
23
Amount of returned premium
$
24
Amount of proceeds if payable in one sum
$
25
Value of proceeds as of date of death (if not payable in one sum)
26
Policy provisions concerning deferred payments or installments.
Note: If other than lump-sum settlement is authorized for a surviving spouse, please attach a copy of
the insurance policy.
$
27
Amount of installments
28
Date of birth, sex, and name of any person the duration of whose life may measure the number of payments.
29
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
Was the insured the annuitant or beneficiary of any annuity contract issued by the company?
Yes
No
32
Names of companies with which decedent carried other policies and amount of such policies if this information is disclosed by your records.
The undersigned officer of the above-named insurance company hereby certifies that this statement sets forth true and correct information.
Signature
Title
Date of Certification
Instructions
the Office of Management and Budget at the addresses listed in the
instructions of the tax return with which this form is filed. DO NOT
Paperwork Reduction Act Notice.—We ask for the information on
send the tax form to either of these offices. Instead, return it to the
this form to carry out the Internal Revenue laws of the United States.
executor or representative who requested it.
You are required to give us the information. We need it to ensure
Statement of Insurer.—This statement must be made, on behalf of
that you are complying with these laws and to allow us to figure and
the insurance company that issued the policy, by an officer of the
collect the right amount of tax.
company having access to the records of the company. For purposes
The time needed to complete and file this form will vary depending
of this statement, a facsimile signature may be used in lieu of a
on individual circumstances. The estimated average time is:
manual signature and if used, shall be binding as a manual signature.
Form
Recordkeeping
Preparing the form
Separate Statements.—A separate statement must be filed for each
712
18 hrs., 25 min.
18 min.
policy.
If you have comments concerning the accuracy of these time
Line 13.—Report on line 13 the annual premium, not the cumulative
estimates or suggestions for making this form more simple, we
premium to date of death. If death occurred after the end of the
would be happy to hear from you. You can write to both the IRS and
premium period, report the last annual premium.
712
Cat. No. 10170V
Form
(Rev. 11-91)

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