Form 8870 - Information Return For Transfers Associated With Certain Personal Benefit Contracts - 2009 Page 3

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3
Form 8870 (Rev. 2-2009)
Page
Continuation Schedule
(You may duplicate this Schedule. See instructions.)
Page
of
Part A. Personal Benefit Contracts (cont.)
(a)
(b)
(c)
Item
Contract Issuer
Policy number
number
Name, address, and ZIP code
No. ____
No. ____
No. ____
Part B. Premiums Paid on Personal Benefit Contracts by the Organization Or Treated as Paid by the Organization (cont.)
(b)
(c)
(e)
(a)
(d)
(f)
Date premium
Amount of
Amount of
Item number
Date premium
Total of amounts in
paid by the
premium paid by
premium paid
from Part A
paid by others
columns (c) and (e)
organization
the organization
by others
No. ____
No. ____
No. ____
(g) Total premiums. Add the amounts in column (f). (Enter here and on Part B, page 1, line (h).)
(g)
Part C. Beneficiaries (cont.)
(a)
(b)
(c)
Item number
Beneficiary’s name, address, and
Beneficiary’s SSN or EIN
from Part A
ZIP code
No. ____
No. ____
No. ____
Part D. Transferors (cont.)
(a)
(b)
(c)
(d)
Item number
Transferor’s name, address, and
Date organization
Amount of
from Part A
ZIP code
received transfer
transfer
No. ____
No. ____
No. ____
8870
Form
(Rev. 2-2009)

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