Form 8921 Draft - Transaction Involving A Pool Of Applicable Insurance Contracts
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28921
Transaction Involving a Pool of Applicable
Form
OMB No. XXXX-XXXX
Insurance Contracts
(March 2007)
Department of the Treasury
(For Tax-Exempt Organizations and Government Entities under Section 6050V)
Internal Revenue Service
See instructions for the required filing date.
1
Structured transaction date
2
Structured transaction identifier (STI)
3
Amended Form 8921
—
/
/
4
Name of organization
Taxpayer identification number (TIN)
Number and street (or P.O. Box if mail is not delivered to street address)
City or town, state or country, and ZIP+4
Internet address
State/Country in which organized
5
Organization’s role in STI (check all that apply):
Contract owner
Contract Beneficiary
Provide insurable interest
Other
6
Check the appropriate box identifying your type of organization
a
Religious, charitable, scientific, literary, educational,
d
Indian tribal government
amateur sports, or similar organization
e
Veterans’ organization
b
Governmental organization
f
Cemetery company
c
Fraternal society operating on a lodge system
g
Employee stock ownership plan
Persons (other than your organization) known to hold (directly or indirectly) an interest in the applicable insurance contracts
7
or who otherwise receive amounts from the section 6050V structured transaction. Do not include insureds. Attach
additional sheets, if necessary.
c Role in
a Name
b Address
d Legal form
e Check if
structured transaction
applicable
(Check all that apply.)
Lender
Individual
Foreign
Investor
Corporation
Broker/Advisor
Partner
Contract Owner
Trust
Tax-Exempt
Contract Beneficiary
Government
Other
Other
Lender
Individual
Foreign
Investor
Corporation
Broker/Advisor
Partner
Contract Owner
Trust
Tax-Exempt
Contract Beneficiary
Government
Other
Other
Lender
Individual
Foreign
Investor
Corporation
Broker/Advisor
Partner
Contract Owner
Trust
Tax-Exempt
Contract Beneficiary
Government
Other
Other
Lender
Individual
Foreign
Investor
Corporation
Broker/Advisor
Partner
Contract Owner
Trust
Tax-Exempt
Contract Beneficiary
Government
Other
Other
8921
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 37732X
Form
(3-2007)
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