Form 712 - Life Insurance Statement Page 3
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Form 712 (Rev. 4-2006)
Page
Instructions
You are not required to provide the information
requested on a form that is subject to the Paperwork
Statement of insurer. This statement must be made,
Reduction Act unless the form displays a valid OMB
on behalf of the insurance company that issued the
control number.
policy, by an officer of the company having access to
Books or records relating to a form or its instructions
the records of the company.
must be retained as long as their contents may
For purposes of this statement, a facsimile signature
become material in the administration of any Internal
may be used in lieu of a manual signature and if used,
Revenue law.
shall be binding as a manual signature.
Generally, tax returns and return information are
Separate statements. File a separate Form 712 for
confidential, as required by section 6103.
each policy.
The time needed to complete and file this form will
Line 13. Report on line 13 the annual premium, not the
vary depending on individual circumstances.
cumulative premium to date of death.
The estimated average time is:
If death occurred after the end of the premium
Recordkeeping
18 hrs., 11 min.
period, report the last annual premium.
Learning about the form
6 min.
Preparing the form
23 min.
Paperwork Reduction Act Notice. We ask for the
If you have comments concerning the accuracy of
information on this form to carry out the Internal
these time estimates or suggestions for making this
Revenue laws of the United States. You are required to
form simpler, we would be happy to hear from you.
give us the information. We need it to ensure that you
are complying with these laws and to allow us to figure
See the instructions for the tax return with which this
and collect the right amount of tax.
form is filed. Do not send the tax form to that office.
Instead, return it to the executor or representative who
requested it.
Printed on recycled paper
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