Instructions For Form 8921 (2007) - Internal Revenue Service (Page 3 of 4) in pdf

Line 8d. Check all boxes that describe the party’s role or roles

Enter on line 13b and 13c the aggregate premiums paid or to

in the structured transaction. If “Other” is checked, provide a

be paid for contracts issued under each separate contract form.

description in the space provided. See Definitions earlier for

Allocate premiums according to whether they have been or will

definitions of roles.

be paid in the first policy year or later. Future premiums are to

be included on line 13c, and should be expected values based

Line 8e. Check the appropriate box that describes the party’s

on contract terms and/or amounts shown in promotional or

legal form. If “Other” is checked, provide a description in the

other materials.

space provided.

Lines 14a and 14b. Enter on line 14a the aggregate value of

Line 8f. Check the box if the party to the structured transaction

death or endowment benefits associated with all contracts

is a foreign entity not subject to U.S. federal income tax.

issued under each separate contract form as of the dates the

Line 8g. Check the box if the party to the structured

contracts were issued.

transaction is an applicable exempt organization.

Enter on line 14b, for each contract form, the smallest and

Line 8h. If the party to the structured transaction is a trust,

the largest contract death or endowment benefit as specified on

partnership, association, or corporation, enter the number of

the date each contract was issued.

trust beneficiaries, partners or association members, or

Lines 15a through 15c. Complete lines 15a through 15c if the

corporate stockholders as of the filing date.

contract type is an immediate annuity. Otherwise, go to line

Line 8i. Report amounts paid or expected to be paid by the

16a.

party under the structured transaction. Amounts to be paid in

the future are expected values based on contract terms and/or

On line 15a, check the “Fixed” box if annuity payments are

amounts shown in promotional or other materials.

fixed in amount or are indexed only to a consumer price index.

Check the “Variable” box if they are dependent upon a fund

Line 8j. Report amounts received by the party to the

value or other index (other than a consumer price index).

structured transaction as of the filing date of this Form 8921.

Whether fixed or variable, check the “Inflation-indexed” box if

Line 8k. Report amounts to be received by the party to the

the annuity is indexed to a consumer or similar price index.

structured transaction in the future. Future amounts are

Enter on line 15b the aggregate value of monthly annuity

expected values, based on contract terms and/or amounts

payments (or monthly equivalent payments, if payments are not

shown in promotional or other materials.

made on a monthly basis) for all contracts issued under each

Line 8l. Check the appropriate box for each reportable person

immediate annuity contract form. This value should reflect

for whom the amounts reported on line 8j or line 8k and/or their

annuity payments when the contracts were first issued.

timing depend on the payment of death or endowment benefits,

Enter on line 15c the values of the smallest and largest

or annuity benefits.

monthly annuity payments (or monthly equivalent payments, if

Part III. Applicable Insurance Contract

payments are not made on a monthly basis) for immediate

annuity contracts issued under each immediate contract form.

Forms

These values should reflect the annuity payments when a

contract was first issued.

Lines 9 through 21

Lines 16a and 16b. Enter on line 16a the aggregate policy

Enter the requested information for each separate contract form

loans made (or expected to be made) under each contract form.

for the structured transaction being reported on this Form 8921.

Enter on line 16b the aggregate value of any other amounts

See Definitions earlier for the definition of a contract form. A

distributed (or expected to be distributed) from each contract

separate column must be used for each contract form. Attach

form (other than as death or annuity benefits or as loans). For

additional sheets as necessary.

example, include any anticipated partial withdrawals of cash

Line 9. Enter a contract form identifier (number or name) that

values or any expected amounts to be received upon the future

can be used to identify the contract being reported in each

surrender of the contracts.

column. Mark any contract form attachments submitted

Line 17. Identify the available investment options under the

according to the line 21 instructions with the appropriate

contract. Check all boxes that apply, even if one or more

contract form identifier.

options are not chosen.

Lines 10a through 10c. Enter the name and employer

identification number of the insurer issuing the contract form,

IF...

THEN check box

for...

and specify the state (or, if a foreign entity, the country) in which

the insurer is organized.

No specified investment option is available (for

No option.

Line 11. Check the box that appropriately identifies the type of

example, when only a guaranteed cash value

applicable insurance contract. An immediate annuity is a

schedule is specified), regardless of whether or not

contract under which the first benefit payment is due within one

policyholder dividends may be paid

year from the date of purchase. Under a deferred annuity,

Fixed or variable rates of interest are specified, but

Guaranteed

payments begin, if at all, at a later date.

there is no possibility that the market value of the

interest.

Lines 12a through 12d. On lines 12a and 12b, enter the

contract cash value may decline due to changes in

earliest and latest dates (MM/DD/YYYY) on which a contract

the market pricing of shares

was issued under each contract form. Enter the total number of

Investments in bond, equity, or blended funds are

Bond or equity

policies issued under each contract form on line 12c. For group

available, and the cash value of the contract

funds.

insurance, enter the number of policy certificates issued under

depends on the market value of the underlying

the group contract on line 12c, and check the box under line

investments

12d. The entry on line 12c should be the number of contracts

(or, in the case of a group contract, the number of certificates),

The contract provides other types of investment

Other. Provide a

and may not correspond to the number of insureds.

options, including options that offer additional

description in the

guarantees as to the contract cash value (for

space provided.

Lines 13a through 13c. On line 13a, check the “Fixed in

example, contracts that guarantee a fixed or variable

contract” box if premium obligations are fixed in amount and

floor on cash values in situations where the market

period by the insurance contract. If premiums are to be paid

value of the underlying investments declines)

over the life of the insured(s), check the box “Life of the

insured.” If the premium term is fixed, check the “years” box and

enter the premium term in years. Check the “Discretionary” box

Lines 18a through 18c. Enter the number of insured males

if premium amounts and timing are determined at the discretion

and insured females for each contract form on line 18a. Specify

of a contract owner.

the average age at issue of all insureds for each contract form

-3-

Instructions For Form 8921 (2007) - Internal Revenue Service Page 3

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