Form 712 - Life Insurance Statement Page 2
Download a blank fillable Form 712 - Life Insurance Statement in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 712 - Life Insurance Statement with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
32
Form 712 (Rev. 4-2006)
Page
Part II
Living Insured
(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.)
SECTION A—General Information
36
First name and middle initial of donor (or decedent)
37
Last name
38
Social security number
39
Date of gift for which valuation data submitted
40
Date of decedent’s death for which valuation data submitted
SECTION B—Policy Information
41
Name of insured
42
Sex
43
Date of birth
44
Name and address of insurance company
45
Type of policy
46
Policy number
47
Face amount
48
Issue date
49
Gross premium
50
Frequency of payment
51
Assignee’s name
52
Date assigned
53
If irrevocable designation of beneficiary made, name of
54
Sex
55
Date of birth,
56
Date
beneficiary
if known
designated
57
If other than simple designation, quote in full. Attach additional sheets if necessary.
58
If policy is not paid up:
a
Interpolated terminal reserve on date of death, assignment, or irrevocable
58a
designation of beneficiary
b
Add proportion of gross premium paid beyond date of death, assignment,
58b
or irrevocable designation of beneficiary
58c
c
Add adjustment on account of dividends to credit of policy
58d
d
Total. Add lines 58a, b, and c.
58e
e
Outstanding indebtedness against policy
58f
f
Net total value of the policy (for gift or estate tax purposes). Subtract line 58e from line 58d
59
If policy is either paid up or a single premium:
a
Total cost, on date of death, assignment, or irrevocable designation of
beneficiary, of a single-premium policy on life of insured at attained age, for
original face amount plus any additional paid-up insurance (additional face
59a
amount $
)
(If a single-premium policy for the total face amount would not have been
issued on the life of the insured as of the date specified, nevertheless, assume
that such a policy could then have been purchased by the insured and state
the cost thereof, using for such purpose the same formula and basis employed,
on the date specified, by the company in calculating single premiums.)
59b
b
Adjustment on account of dividends to credit of policy
59c
c
Total. Add lines 59a and 59b
59d
d
Outstanding indebtedness against policy
e
Net total value of policy (for gift or estate tax purposes). Subtract line 59d from line 59c
59e
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.
Date of
Signature
Title
Certification
712
Form
(Rev. 4-2006)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial