Form 8870 - Information Return For Transfers Associated With Certain Personal Benefit Contracts Page 2

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Form 8870 (Rev. 8-2013)

Page

Part C. Beneficiaries

(a)

(b)

(c)

Item number

Beneficiary’s name, address, and

Beneficiary’s SSN or EIN

from Part A

ZIP code

No.

Part D. Transferors

(a)

(b)

(c)

(d)

Item number

Transferor’s name, address, and

Date organization

Amount of

from Part A

ZIP code

received transfer

transfer

No.

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge

and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge.

Sign

Here

Signature of officer

Date

Type or print name and title.

Print/Type preparer’s name

PTIN

Preparer’s signature

Date

Paid

Check

self-employed